1
|
Li Y, Ren T, Burgess M, Chen Z, Carney PW, O’Brien TJ, Kwan P, Foster E. Early Access to First-Seizure Clinics, Subsequent Outcomes, and Factors Associated With Attendance. JAMA Neurol 2024; 81:732-740. [PMID: 38778793 PMCID: PMC11117147 DOI: 10.1001/jamaneurol.2024.1187] [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: 11/27/2023] [Accepted: 03/14/2024] [Indexed: 05/25/2024]
Abstract
Importance First-seizure clinics (FSCs) aim to deliver prompt specialist care to patients with new-onset undifferentiated seizure events. Objective To determine whether FSC attendance and time to FSC are associated with subsequent health care utilization and mortality and to investigate factors associated with FSC nonattendance. Design, Setting, and Participants This was a record-linkage, retrospective, cohort study of patients who booked appointments at 2 FSCs between 2007 and 2018. Patients' records were linked to state-wide administrative databases between 2000 and 2021. The setting comprised the FSCs of 2 major metropolitan public hospitals in Melbourne, Australia, providing national inpatient and outpatient adult epilepsy services. Of patients who booked appointments at the FSCs, those who were successfully linked for analysis were included in the study. Patients who recorded only canceled appointments were excluded from analysis of outcomes. Study data were analyzed from January 2000 to December 2021. Exposure FSC attendance. Main Outcomes and Measures Subsequent all-cause and seizure-related emergency department (ED) presentations and hospital admissions. Results Of 10 162 patients with appointments at FSCs, 9392 were linked for analysis, with mean (SD) follow-up time 6.9 (2.8) years after FSC referral. A total of 703 patients were excluded. Among 9392 linked patients, 5398 were male (57.5%; mean [SD] age, 59.7 [11.2] years). FSC attendance was associated with reduced subsequent all-cause emergency presentations (adjusted incidence rate ratio [aIRR], 0.72; 95% CI, 0.66-0.79) and all-cause hospitalization (aIRR, 0.81; 95% CI, 0.75-0.88). Those who attended at the first-scheduled appointment, compared with those who attended only a rescheduled, delayed appointment, had reduced subsequent all-cause emergency presentations (aIRR, 0.83; 95% CI, 0.76-0.91), all-cause hospitalization (aIRR, 0.71; 95% CI, 0.65-0.79), seizure-related presentations (aIRR, 0.40; 95% CI, 0.33-0.49), and mortality (hazard ratio, 0.82; 95% CI, 0.69-0.98). Male sex was associated with nonattendance (adjusted relative risk [aRR], 1.12; 95% CI, 1.03-1.22), as were injury at emergency presentation (aRR, 1.12; 95% CI, 1.01-1.24), psychiatric comorbidity (aRR, 1.68; 95% CI, 1.55-1.81), previous seizure-related presentations (aRR, 1.35; 95% CI, 1.22-1.49), and delays (>14 days) between FSC referral and appointment (aRR, 1.35; 95% CI, 1.18-1.54). Hospitalization at referral was associated with reduced nonattendance (aRR, 0.80; 95% CI, 0.72-0.90), as were non-English language preference (aRR, 0.81; 95% CI, 0.69-0.94), distance greater than 6 mi from home to clinic (aRR, 0.85; 95% CI, 0.76-0.95), and physical comorbidity (aRR, 0.80; 95% CI, 0.72-0.89). Conclusions and Relevance Results of this cohort study suggest that FSC attendance, particularly early attendance, was associated with reduced rates of subsequent hospital utilization. This knowledge may support adequately resourcing FSCs to improve equitable, timely access. Future study directions include assessing interventions that may support FSC attendance for at-risk groups.
Collapse
Affiliation(s)
- Yingtong Li
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Tianrui Ren
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Michael Burgess
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Zhibin Chen
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Patrick W. Carney
- Department of Neurology, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Victoria, Australia
- The Florey, Melbourne Brain Centre, Heidelberg, Victoria, Australia
| | - Terence J. O’Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Patrick Kwan
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Emma Foster
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
2
|
Lee SH, Gillespie C, Bandyopadhyay S, Nazari A, Ooi SZY, Park JJ, Champ C, Taylor C, Kinney M, Mackay G, Myint PK, Marson A. National audit of pathways in epileptic seizure referrals (NAPIER): A national, multicentre audit of first seizure clinics throughout the UK and Ireland. Seizure 2023; 111:165-171. [PMID: 37639958 DOI: 10.1016/j.seizure.2023.08.010] [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: 06/08/2023] [Revised: 07/28/2023] [Accepted: 08/18/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Current guidelines set clinical standards for the management of suspected first seizures and epilepsy. We aimed to assess if these standards are being met across first seizure clinics nationally, to describe variations in care and identify opportunities for service delivery improvement. METHODS Multicentre audit assessing the care of adults (≥16 years) referred to first seizure clinics from 31st December 2019 going backwards (30 consecutive patients per centre). Patients with pre-existing diagnosis of epilepsy were excluded. Anonymised referral, clinic, and follow-up data are reported with descriptive statistics. RESULTS Data provided for 727 patients from 25 hospitals in the UK and Ireland (median age 41 years [IQR 26-59], 52% males). Median time to review was 48 days (IQR 26-86), with 13.8% (IQR 3.3%-24.0%) of patients assessed within 2 weeks. Seizure recurrence was seen in 12.7% (IQR 6.6%-17.4%) of patients awaiting first appointment. Documentation for witness accounts and driving advice was evident in 85.0% (IQR 74.0%-100%) and 79.7% (IQR 71.2%-96.4%) of first seizure/epilepsy patients, respectively. At first appointment, discussion of sudden unexpected death in epilepsy was documented in 30.1% (IQR 0%-42.5%) of patients diagnosed with epilepsy. In epilepsy patients, median time to MRI neuroimaging was 37 days [IQR 22-56] and EEG was 30 days [IQR 19-47]. 30.4% ([IQR 0%-59.5%]) of epilepsy patients were referred to epilepsy nurse specialists. CONCLUSIONS There is variability nationally in the documented care of patients referred to first seizure clinics. Many patients are facing delays to assessment with epilepsy specialists with likely subsequent impact on further management.
Collapse
Affiliation(s)
- Seong Hoon Lee
- Department of Neurology, Aberdeen Royal Infirmary, NHS Grampian, UK; Institute of Applied Health Sciences, School of Medicine, University of Aberdeen, UK.
| | - Conor Gillespie
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, UK; Department of Neurology, The Walton Centre NHS Foundation Trust, UK
| | - Soham Bandyopadhyay
- Oxford University Global Surgery Group, Nuffield Department of Surgical Sciences, University of Oxford, UK
| | - Armin Nazari
- University of Dundee Medical School, University of Dundee, UK
| | | | - Jay J Park
- University of Edinburgh Division of Clinical and Surgical Sciences, University of Edinburgh, UK
| | | | - Claire Taylor
- Liverpool Clinical Trials Centre, University of Liverpool, Faculty of Health and Life Sciences, UK
| | - Michael Kinney
- Department of Neurology, Royal Victoria Hospital, Belfast Health & Social Care Trust, UK
| | - Graham Mackay
- Department of Neurology, Aberdeen Royal Infirmary, NHS Grampian, UK
| | - Phyo Kyaw Myint
- Ageing Clinical & Experimental Research (ACER) Team, Institute of Applied Health Sciences, University of Aberdeen, UK
| | - Anthony Marson
- Department of Neurology, The Walton Centre NHS Foundation Trust, UK; Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, UK
| |
Collapse
|
3
|
Jenkins C, Cabrera A, Goldenholz DM, Losey T, Baker NA, Estes M, Casassa CM. Gaps in care following first time seizure in an underserved region: A retrospective analysis. Seizure 2023; 108:96-101. [PMID: 37146517 PMCID: PMC10213122 DOI: 10.1016/j.seizure.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 04/17/2023] [Accepted: 04/19/2023] [Indexed: 05/07/2023] Open
Abstract
PURPOSE This study investigated the characteristics of patients presenting with the first-time seizure (FTS) and whether neurology follow-up occurred in a medically underserved area. METHODS A retrospective study of adults with a FTS discharged from the Emergency Department (ED) at Loma Linda University between January 1, 2017 and December 31, 2018 was performed. The primary outcome was days from the ED visit to the first neurology visit. Secondary outcomes included repeat ED visits, percentage of patients who had specialty assessment in one year, type of neurologist seen, and percentage lost to follow-up. RESULTS Of the 1327 patients screened, 753 encounters met criteria for manual review, and after exclusion criteria were applied, 66 unique encounters were eligible. Only 30% of FTS patients followed up with a neurologist. The median duration for neurology follow-up was 92 days (range=5-1180). After initial ED visit, 20% of follow-up patients were diagnosed with epilepsy within 189 days, and 20% of patients re-presented to the ED with recurrent seizures while awaiting their initial neurology appointment. Reasons for lack of follow-up included: referral issues, missed appointments, and shortage of available neurologists. CONCLUSION This study highlights the significant treatment gap that a first-time seizure clinic (FTSC) could fill in underserved communities. FTSC may reduce the morbidity and mortality associated with untreated recurrent seizures.
Collapse
Affiliation(s)
| | - Andrew Cabrera
- Loma Linda School of Medicine, 11175 Campus St, Loma Linda, CA 92350, USA.
| | - Daniel M Goldenholz
- Division of Epilepsy, Department of Neurology, Beth Israel Deaconess Medical Center, 330 Brookline Ave, Boston, MA 02215, USA; Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
| | - Travis Losey
- Department of Neurology, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| | - Nancy A Baker
- Department of Neurology, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| | - Molly Estes
- Department of Emergency Medicine, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| | - Charles M Casassa
- Department of Neurology, Loma Linda University Medical Center, 11234 Anderson St, Loma Linda, CA 92354, USA.
| |
Collapse
|
4
|
Epilepsy in Older Persons. Neurol Clin 2022; 40:891-905. [DOI: 10.1016/j.ncl.2022.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
5
|
Green SF, Loefflad N, Heaney DC, Rajakulendran S. New-onset seizures in older people: Clinical features, course and outcomes. J Neurol Sci 2021; 429:118065. [PMID: 34492571 DOI: 10.1016/j.jns.2021.118065] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVE The incidence of epilepsy increases with age. With current demographic trends, this presents a healthcare challenge. We investigated the clinical spectrum of first seizures, evaluated neuroimaging and EEG findings, and determined clinical outcomes, including anti-seizure medication (ASM) response in older people. In addition, we sought to understand the relative effects of age and frailty on ASM response. METHODS A retrospective single centre cohort study of 207 cases ≥60 years' old, 113 of whom were eventually diagnosed with a first seizure in a specialist epilepsy clinic. RESULTS 65/113 (57.5%) presented with either focal aware or focal impaired awareness seizures. Stroke was the most common aetiological association (31.9%, 36/113), and odds of seizure recurrence did not significantly differ between aetiologies. 55/86 (64.0%) who started an ASM had no seizure recurrence. 14/48 (29.2%) who underwent EEG had epileptiform abnormalities, however EEG result directly affected management in only 4/48 (8.3%). The most common MRI findings were small vessel disease (37/93, 39.8%), stroke (27/93, 29.0%) and global atrophy (14/93, 15.1%). Increasing age and frailty did not affect the odds of seizure recurrence or of experiencing ASM side effects. Severity of small vessel disease or atrophy did not affect odds of seizure recurrence. CONCLUSION Our data inform the management of first seizures in older people and provisionally support the use of ASMs in patients with increasing age and frailty, despite concerns over polypharmacy and comorbidity. Our findings should be replicated in larger cohorts.
Collapse
Affiliation(s)
- Sebastian F Green
- Epilepsy Department, National Hospital for Neurology and Neurosurgery, London, UK; Institute of Clinical Neurosciences, North Bristol NHS Trust, Bristol, UK
| | | | - Dominic C Heaney
- Epilepsy Department, National Hospital for Neurology and Neurosurgery, London, UK
| | - Sanjeev Rajakulendran
- Epilepsy Department, National Hospital for Neurology and Neurosurgery, London, UK; UCL Queen Square Institute of Neurology, London, UK.
| |
Collapse
|
6
|
Hudson ER, Lesko A, Lucas L, Baraban E, Fertig EJ. Healthcare utilization and cost outcomes for a multicenter first seizure and new onset epilepsy clinic. Epilepsy Behav 2021; 120:107972. [PMID: 33971392 DOI: 10.1016/j.yebeh.2021.107972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 03/15/2021] [Accepted: 04/01/2021] [Indexed: 11/26/2022]
Abstract
RATIONALE A First Seizure/New Onset Epilepsy (FS/NOE) protocol was implemented to ensure proper evaluation by an epileptologist and improve overall care for patients. We compared healthcare utilization and cost incurred by patients pre and post protocol implementation. METHODS Clinical data were retrospectively collected from the EMR and cost data from the financial database. Patients were identified by FS event and grouped into either the pre-implementation (pre-FSC) or post-implementation cohort (post-FSC). Pre-FSC patients were seen between January 2014-December 2015 and post-FSC between March 2016-January 2018. Utilization outcomes include time from FS to neurology appointment, MRI, and electroencephalogram (EEG). Cost outcomes included the annualized median difference in pre versus post costs for ER, inpatient, outpatient or ambulatory, and total hospital services. Cost and utilization outcomes were collected within 90 days or 6 months post first-seizure event. Pre and post cohorts were compared using Kaplan-Meier analysis and Cox proportional hazard models for time-to-event outcomes, multivariable median regression models for cost differences and negative binomial regression models for utilization analyses. Models were adjusted for age, sex, health insurance, and comorbidities. RESULTS One-hundred and fifty six patients were included with 84 (53.8%) pre- and 72 (46.2%) post-FSC patients. Kaplan-Meier and Cox regression results indicated post-FSC patients had significantly faster time-to-first neurology appointment (5.0 vs. 20.9 days, p < .001; Adjusted Hazard Ratio (HR) = 5.98, p < .001), time-to-MRI (9.0 vs. 27.0 days; p = 0.005; HR = 1.88, p = .021) and EEG (3.6 vs. 48.6 days, p < .001; HR = 9.01, p < .001). A total of 138 patients had at least one cost in the financial database. For 6-month follow-up period, post-FSC patients had higher adjusted all-cause total median costs (+$830, p = 0.009) and outpatient costs (+$1203, p < .001) but lower ED costs (-245, p = 0.073), not significant. Results were similar for seizure-related costs. Similarly, Post-FSC patients had a significantly higher likelihood of all-cause (Adjusted Rate Ratio (ARR) = 1.41, p = .029) and outpatient utilization (ARR = 1.72, p = .008) but lower ED utilization (ARR = 0.54, p < .001). CONCLUSIONS Implementation of the FSC decreased time to evaluation by a neurologist and time to diagnostic workup. Ultimately, total healthcare costs and ambulatory costs increased but ED costs and utilization were reduced. It is our hypothesis that faster access to initial care and diagnosis would result in better control of seizures and reduce long-term costs and utilization. Further research over a longer duration of time across a broader population is needed to evaluate the full implications of an epilepsy specialist-populated FSC.
Collapse
Affiliation(s)
- Emily R Hudson
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States
| | - Alexandra Lesko
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States.
| | - Lindsay Lucas
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States
| | - Elizabeth Baraban
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States
| | - Evan J Fertig
- Western University of Health Sciences College of Osteopathic Medicine of the Pacific, Northwest, 200 Mullins Dr, Lebanon, OR 97355, United States; Providence Brain and Spine Institute, 9135 SW Barnes Rd., Suite 363, Portland, OR 97225, United States
| |
Collapse
|