Impact of insurance status on access to care and out-of-pocket costs for U.S. individuals with epilepsy

Health insurance and transportation barriers impact access to epilepsy care in the United States

PURPOSE

Inconsistent access to healthcare for people with epilepsy results in reduced adherence to antiseizure medications, increased seizure frequency, and fewer appropriate referrals for epilepsy surgery. Identifying and addressing factors that impede access to care should consequently improve patient outcomes. We hypothesized that health insurance and transportation affect access to outpatient neurology care for adults living with epilepsy in the United States (US).

METHODS

We conducted a retrospective cross-sectional study of US adults with active epilepsy surveyed via the National Health Interview Survey (NHIS) in 2015 and 2017. We established whether patients reported seeing a neurologist in the past year and used multiple logistic regression to determine whether health insurance status and transportation access were associated with this outcome.

RESULTS

We identified 735 respondents from 2015 and 2017, representing an estimated 2.98 million US adults with active epilepsy. After adjusting for socioeconomic and seizure-related co-variates, we found that a lack of health insurance coverage was associated with no epilepsy care in the past year (adjusted odds ratio [aOR] 0.22; 95 % confidence interval [CI]: 0.09 - 0.54). Delayed care due to inadequate transportation (aOR 0.42; 95 % CI: 0.19 - 0.93) also resulted in reduced patient access to a neurologist.

CONCLUSION

Due to the inherent nature of their condition, people with epilepsy are less likely to have employer-sponsored health insurance or consistent driving privileges. Yet, these factors also impact patient access to neurological care. We must address transportation and insurance barriers through long-term investment and partnership between community, healthcare, and government stakeholders.

Higher Out-of-pocket Expenses are Associated with Worse Health-related Quality of Life in Burn Survivors: A Northwest Regional Burn Model System Investigation

The care required to recover serious burn injuries is costly. In the United States, these costs are often borne by patients. Examining the relationship between out-of-pocket (OOP) costs and health-related quality of life (HRQL) is important to support burn survivors. Financial data from a regional burn center were merged with data in the Burn Model System (BMS) National Database. HRQL outcomes included VA-Rand 12 (VR-12) physical component summary (PCS) and mental component summary (MCS) scores. Participant surveys were conducted at 6-, 12-, and 24-months post-injury. VR-12 scores were evaluated using generalized linear models and adjusted for potential confounders (age, sex, insurance/payer, self-identified race/ethnicity, measures of burn injury severity). 644 participants were included, of which 13% (84) had OOP costs. The percentage of participants with OOP costs was 34% for commercial/private, 22% for Medicare, 8% for other, 4% for self-pay, and 0% for workers' compensation and Medicaid. For participants with OOP expenses, median payments were $875 with an IQR of $368-1728. In addition to markers of burn injury severity, OOP costs were negatively associated with PCS scores at 6-months (coefficient -0.002, P < .001) and 12-months post-injury (coefficient -0.001, P = .004). There were no significant associations with PCS scores at 24 months post-injury or MCS scores at any interval. Participants with commercial/private or Medicare payer had higher financial liability than other payers. Higher OOP expenses were negatively associated with physical HRQL for at least 12 months after injury. Financial toxicity occurs after burn injury and providers should target resources accordingly.

Health equity integrated epilepsy care and research: A narrative review

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.

Differences in elective epilepsy monitoring unit admission rates by race/ethnicity and primary payer in New Jersey

Elective admission to the epilepsy monitoring unit (EMU) is an essential service provided by epilepsy centers, particularly for those with drug-resistant epilepsy. Given previously characterized racial and socioeconomic healthcare disparities in the management of epilepsy, we sought to understand access and utilization of this service in New Jersey (NJ). We examined epilepsy hospitalizations in NJ between 2014 and 2016 using state inpatient and emergency department (ED) databases. We stratified admissions by race/ethnicity and primary payer and used these to estimate and compare (1) admission rates per capita in NJ, as well as (2) admission rates per number of ED visits for each group. Patients without insurance underwent elective EMU admission at the lowest rates across all racial/ethnic groups and payer types studied. Black patients with Medicaid and private insurance were admitted at disproportionately low rates relative to their number of ED visits. Hispanic/Latino and Asian/Pacific Islanders with private insurance, Hispanic/Latinos with Medicaid, and Asian/Pacific Islanders with Medicare were also admitted at low rates per capita within each respective payer category. Future studies should focus on addressing causal factors driving healthcare disparities in epilepsy, particularly for patients without adequate health insurance coverage and those who have been historically underserved by the healthcare system.

Utilization of public health care by people with private health insurance: a systematic review and meta-analysis

Background

The objective of this systematic review was to explore the association between private health insurance and health care utilization.

Methods

We searched the MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) electronic databases for relevant articles since 2010. Studies were eligible if they described original empirical research on the utilization of public health care by individuals with private health insurance, compared with individuals without private insurance. A pooled measure of association between insurance status with health care utilization was assessed through meta-analysis.

Results

Twenty-six articles were included in the final analysis. We found that patients with private insurance did not use more public health care than people without private insurance (P < 0.05). According to the subgroup analysis, people with private insurance were more likely to be hospitalized than people with no insurance (OR 1.67; 95% CI, 1.18 to 2.36).

Conclusions

People with private insurance did not increase their use of health care (outpatient services), compared to those without private insurance. Private health insurance coverage may ease the financial burden on patients and on the public health insurance system.

Socioeconomic disparities in SUDEP in the US

OBJECTIVE

To determine the impact of socioeconomic status (SES) on sudden unexpected death in epilepsy (SUDEP) rates.

METHODS

We queried all decedents presented for medico-legal investigation at 3 medical examiner (ME) offices across the country (New York City, Maryland, San Diego County) in 2009 to 2010 and 2014 to 2015. We identified all decedents for whom epilepsy/seizure was listed as cause/contributor to death or comorbid condition on the death certificate. We then reviewed all available reports. Decedents determined to have SUDEP were included for analysis. We used median income in the ZIP code of residence as a surrogate for SES. For each region, zip code regions were ranked by median household income and divided into quartiles based on total population for 2 time periods. Region-, age-, and income-adjusted epilepsy prevalence was estimated in each zip code. SUDEP rates in the highest and lowest SES quartiles were evaluated to determine disparity. Examined SUDEP rates in 2 time periods were also compared.

RESULTS

There were 159 and 43 SUDEP cases in the lowest and highest SES quartiles. ME-investigated SUDEP rate ratio between the lowest and highest SES quartiles was 2.6 (95% confidence interval [CI] 1.7-4.1, p < 0.0001) in 2009 to 2010 and 3.3 (95% CI 1.9-6.0, p < 0.0001) in 2014 to 2015. There was a significant decline in overall SUDEP rate between the 2 study periods (36% decrease, 95% CI 22%-48%, p < 0.0001).

CONCLUSION

ME-investigated SUDEP incidence was significantly higher in people with the lowest SES compared to the highest SES. The difference persisted over a 5-year period despite decreased overall SUDEP rates.

High health care costs in minority groups of older US Medicare beneficiaries with epilepsy

OBJECTIVE

To examine health care costs in diverse older Medicare beneficiaries with epilepsy.

METHODS

Using 2008-2010 claims data, we conducted a longitudinal cohort study of a random sample of Medicare beneficiaries augmented for minority representation. Epilepsy cases (n = 36 912) had ≥1 International Classification of Diseases, Ninth Edition (ICD-9) 345.x or ≥2 ICD-9 780.3x claims, and ≥1 antiepileptic drug (AED) in 2009; new cases (n = 3706) had no seizure/epilepsy claims nor AEDs in the previous 365 days. Costs were measured by reimbursements for all care received. High cost was defined as follow-up 1-year cost ≥ 75th percentile. Logistic regressions examined association of high cost with race/ethnicity, adjusting for demographic, clinical, economic, and treatment quality factors. In cases with continuous 2-year data, we obtained costs in two 6-month periods before and two after the index event.

RESULTS

Cohort was ~62% African Americans (AAs), 11% Hispanics, 5% Asians, and 2% American Indian/Alaska Natives. Mean costs in the follow-up were ~$30 000 (median = $11 547; new cases, mean = $44 642; median = $25 008). About 19% white compared to 27% AA cases had high cost. AA had higher odds of high cost in adjusted analyses (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.11-1.29), although this was only marginally significant when adjusting for AED adherence (OR = 1.09, 95% CI = 1.01-1.18, P = 0.03). Factors associated with high cost included ≥1 comorbidity, neurological care, and low AED adherence. Costs were highest at ~$17 000 in the 6 months immediately before and after the index event (>$29 000 for new cases).

SIGNIFICANCE

The financial sequelae of epilepsy among older Americans disproportionally affect minorities. Studies should examine contributors to high costs.

Insurance transitions and healthcare utilization for children with refractory epilepsy

OBJECTIVES

The objective of the study is to investigate the association between insurance transitions and healthcare utilization among children with refractory epilepsy.

METHODS

We applied published algorithms to identify the study cohort of children with a diagnosis of refractory epilepsy who were treated between 10/1/2013 and 9/30/2014 at 36 children's hospitals in the United States. Insurance transition was defined as having any change in the type of primary payer from the first date of diagnosis to the date of the last visit at the same hospital. Univariate and multilevel multivariable analytical methods were used in the study.

RESULTS

Among 3488 children hospitalized with refractory epilepsy, rates of insurance transitions at 1, 2, and 5 years of refractory epilepsy diagnosis were 8.1%, 14%, and 29.9%, respectively. Patients whose primary payer at diagnosis was Private or Others were more likely to experience insurance transitions than patients whose primary payer was Medicaid. Younger children were associated with a higher risk of insurance transitions than older children. The high intensity of insurance transitions was associated with a higher number of emergency department and inpatient visits.

CONCLUSIONS

Insurance transitions interrupted the continuity of medical care for children with refractory epilepsy and were associated with more frequent hospitalizations and emergency department visits, which then translated to higher healthcare costs. Medicaid provided stable insurance coverage and is critically important for these patients and should be the main focus for policies aiming to minimize insurance transitions and optimize healthcare delivery.

The burden of out of pocket costs and medical debt faced by households with chronic health conditions in the United States

Introduction

To examine the relationship between chronic health conditions and out-of-pocket costs (OOPC) and medical debt.

Methods

Secondary data from the 2013 Panel Study of Income Dynamics (PSID) was used. Households whose head of household and spouse (for married households) were 18 to 64 years old were included.

Results

Households with 1 to 3 chronic conditions had higher odds of having any OOPC compared to households with no chronic conditions (AOR 1.74, 95% CI 1.39, 2.17) (p < .01). Households with 1 to 3 and 4 or more chronic health conditions were associated with higher odds of having any medical debt (AOR 2.24, 95% CI 1.75 to 2.87; AOR 5.04, 95% CI 3.04 to 8.34) compared to those with no chronic conditions (p < 0.01). Similarly, 1 to 3 and 4 or more chronic health conditions was associated with higher amounts of OOPC (Exponentiated Coefficient 1.18, 95% CI 1.03 to 1.36; Exponentiated Coefficient 1.56, 95% CI 1.17 to 2.07) and medical debt (Exponentiated Coefficient 1.69, 95% CI 1.23 to 2.34; Exponentiated Coefficient 2.73, 95% CI 1.19 to 6.25) compared to households with no chronic conditions (p < 0.05).

Conclusions

Findings from this study show that the presence of chronic health conditions impose a large financial burden on some households.

Complementary health insurance, out- of- pocket expenditures, and health services utilization: A population- based survey

Background: Studies have shown that people using complementary health insurances have more access to health services than others. In the present study, we aimed at finding the differences between out- of- pocket payments and health service utilizations in complementary health insurances (CHIs) users and nonusers. Methods: Propensity score matching was used to compare the 2 groups. First, confounder variables were identified, and then propensity score matching was used to compare out- of- pocket expenditures with dental, general physician, hospital inpatient, emergency services, nursing, midwifery, laboratory services, specialists and rehabilitation services utilization. Results: Our results revealed no significant differences between the 2 groups in out- of- pocket health expenditures. Also, the specialist visits, inpatient services at the hospital, and dental services were higher in people who used CHIs compared to nonusers. Conclusion: People did not change their budget share for health care services after using CHIs. The payments were equal for people who were not CHIs users due to the increase in the quantity of the services.

The economic impact of epilepsy: a systematic review

BACKGROUND

In this review we aimed to determine the economic impact of epilepsy and factors associated with costs to individuals and health systems.

METHODS

A narrative systematic review of incidence and case series studies with prospective consecutive patient recruitment and economic outcomes published before July 2014 were retrieved from Medline, Embase and PsycInfo.

RESULTS

Of 322 studies reviewed, 22 studies met the inclusion criteria and 14 were from high income country settings. The total costs associated with epilepsy varied significantly in relation to the duration and severity of the condition, response to treatment, and health care setting. Where assessed, 'out of pocket' costs and productivity losses were found to create substantial burden on households which may be offset by health insurance. However, populations covered ostensibly for the upfront costs of care can still bear a significant economic burden.

CONCLUSIONS

Epilepsy poses a substantial economic burden for health systems and individuals and their families. There is uncertainty over the degree to which private health insurance or social health insurance coverage provides adequate protection from the costs of epilepsy. Future research is required to examine the role of different models of care and insurance programs in protecting against economic hardship for this condition, particularly in low and middle income settings.

Does adherence to epilepsy quality measures correlate with reduced epilepsy-related adverse hospitalizations? A retrospective experience

In 2011, the American Academy of Neurology (AAN) established eight epilepsy quality measures (EQMs) for chronic epilepsy treatment to address deficits in quality of care. This study assesses the relationship between adherence to these EQMs and epilepsy-related adverse hospitalizations (ERAHs). A retrospective chart review of 475 new epilepsy clinic patients with an ICD-9 code 345.1-9 between 2010 and 2012 was conducted. Patient demographics, adherence to AAN guidelines, and annual number of ERAHs were assessed. Fisher's exact test was used to assess the relationship between adherence to guidelines (as well as socioeconomic variables) and the presence of one or more ERAH per year. Of the eight measures, only documentation of seizure frequency, but not seizure type, correlated with ERAH (relative risk [RR] 0.343, 95% confidence interval [CI] 0.176-0.673, p = 0.010). Among patients in the intellectually disabled population (n = 70), only review/request of neuroimaging correlated with ERAH (RR 0.128, 95% CI 0.016-1.009, p = 0.004). ERAHs were more likely in African American patients (RR 2.451, 95% CI 1.377-4.348, p = 0.008), Hispanic/Latino patients (RR 4.016, 95% CI 1.721-9.346, p = 0.016), Medicaid patients (RR 2.217, 95% CI 1.258-3.712, p = 0.009), and uninsured patients (RR 2.667, 95% CI 1.332-5.348, p = 0.013). In this retrospective series, adherence to the eight AAN quality measures did not strongly correlate with annual ERAH.

Influence of socio-demographic characteristics on eye care expenditure: data from the Medical Expenditure Panel Survey 2007

OBJECTIVE

To evaluate the association between sociodemographic factors and eye care expenditure and to assess the burden of ocular expenditure compared to total health care expenditure.

METHODS

A retrospective analysis of ocular expenditure in participants of the 2007 Medical Expenditure Panel Survey. Data from 20,620 unique participants aged ≥18 years were evaluated for eye care expenditure by demographic characteristics.

RESULTS

A total of 22% of the studied population had eye care expenditures in 2007. Demographic factors significantly associated with higher probability of having eye care expenditures included older age (65+ years 35%, 45-64 years 23%, <45 years 17%), female sex (female 26%, male 19%), higher educational attainment (greater than high school education 25%, less than high school education 17%), having insurance (private 24%, uninsured 13%), and visual impairment (mild 31%, none 22%). Older age, female sex, higher educational attainment, having insurance, and presence of visual impairment were also significantly associated with higher mean eye care expenditure. In those with eye care expenditure, the mean ratio between eye care and total medical expenditure was 24%, with uninsured patients spending 42% of their medical care expenditure on eye care.

CONCLUSIONS

Demographic factors are associated with both the probability of having ocular expenditure and the amount of expenditure. Of all factors examined, insurance status has the most potential for modification. Policy makers should consider these numbers when devising the terms by which eye care coverage will be provided under the Patient Protection and Affordable Care Act.

Neurologists' knowledge of and attitudes toward epilepsy surgery: a national survey

OBJECTIVES

In the current study, we aim to assess potential neurologist-related barriers to epilepsy surgery among Canadian neurologists.

METHODS

A 29-item, pilot-tested questionnaire was mailed to all neurologists registered to practice in Canada. Survey items included the following: (1) type of medical practice, (2) perceptions of surgical risks and benefits, (3) knowledge of existing practice guidelines, and (4) barriers to surgery for patients with epilepsy. Neurologists who did not complete the questionnaire after the initial mailing were contacted a second time by e-mail, fax, or telephone. After this reminder, the survey was mailed a second time to any remaining nonresponders.

RESULTS

In total, 425 of 796 neurologists returned the questionnaire (response rate 53.5%). Respondents included 327 neurologists who followed patients with epilepsy in their practice. More than half (56.6%) of neurologists required patients to be drug-resistant and to have at least one seizure per year before considering surgery, and nearly half (48.6%) failed to correctly define drug-resistant epilepsy. More than 75% of neurologists identified inadequate health care resources as the greatest barrier to surgery for patients with epilepsy.

CONCLUSIONS

A substantial proportion of Canadian neurologists are unaware of recommended standards of practice for epilepsy surgery. Access also appears to be a significant barrier to epilepsy surgery and surgical evaluation. As a result, we are concerned that patients with epilepsy are receiving inadequate care. A greater emphasis must be placed on knowledge dissemination and ensuring that the infrastructure and personnel are in place to allow patients to have timely access to this evidence-based treatment.

Medicaid status is associated with higher surgical site infection rates after spine surgery

STUDY DESIGN

The Spine End Results Registry (2003-2004) is a registry of prospectively collected data of all patients undergoing spinal surgery at the University of Washington Medical Center and Harborview Medical Center. Insurance data were prospectively collected and used in multivariate analysis to determine risk of perioperative complications.

OBJECTIVE

Given the negative financial impact of surgical site infections (SSIs) and the higher overall complication rates of patients with a Medicaid payer status, we hypothesized that a Medicaid payer status would have a significantly higher SSI rate.

SUMMARY OF BACKGROUND DATA

The medical literature demonstrates lesser outcomes and increased complication rates in patients who have public insurance than those who have private insurance. No one has shown that patients with a Medicaid payer status compared with Medicare and privately insured patients have a significantly increased SSI rate for spine surgery.

METHODS

The prospectively collected Spine End Results Registry provided data for analysis. SSI was defined as treatment requiring operative debridement. Demographic, social, medical, and the surgical severity index risk factors were assessed against the exposure of payer status for the surgical procedure.

RESULTS

The population included Medicare (N = 354), Medicaid (N = 334), the Veterans' Administration (N = 39), private insurers (N = 603), and self-pay (N = 42). Those patients whose insurer was Medicaid had a 2.06 odds (95% confidence interval: 1.19-3.58, P = 0.01) of having a SSI compared with the privately insured.

CONCLUSION

The study highlights the increased cost of spine surgical procedures for patients with a Medicaid payer status with the passage of the Patient Protection and Affordable Care Act of 2010. The Patient Protection and Affordable Care Act of 2010 provisions could cause a reduction in reimbursement to the hospital for taking care of patients with Medicaid insurance due to their higher complication rates and higher costs. This very issue could inadvertently lead to access limitations.

LEVEL OF EVIDENCE

3.

The impact of insurance instability on health service utilization: does non-metropolitan residence make a difference?

PURPOSE

Discontinuous and no health insurance are major barriers to health care utilization. This paper examines if nonmetropolitan versus metropolitan residence is associated with differences in health care utilization in the face of insurance instability.

METHODS

A cross-sectional analysis of adults aged 18-64 years was conducted using the 2006-2010 Medical Expenditure Panel Survey data set (N = 61,039). Negative binomial regression was used to model measures of health service utilization (emergency room [ER] visits, inpatient discharges, office-based visits, dental care visits, prescriptions filled, home health visits) as functions of insurance continuity, adjusted for sociodemographic and health-related covariates. Models were stratified by metropolitan versus nonmetropolitan residence.

FINDINGS

Health insurance continuity was significantly associated with several measures of health service utilization, including more ER visits for individuals with gaps in health insurance (IRR [incident risk ratio] = 1.29; 95% CI: 1.16-1.42) and fewer inpatient discharges for individuals without insurance (IRR = 0.50; 95% CI: 0.43-0.57) when compared with individuals with continuous insurance. Individuals who were discontinuously insured or uninsured had significantly fewer office-based visits. They also had significantly fewer dental visits, prescription fills, and home health visits; moreover, the magnitudes of these associations were generally significantly greater for residents of nonmetropolitan areas.

CONCLUSIONS

Insurance instability is associated with higher use of emergency services and reduced use of nonhospital health care services. Residents of nonmetropolitan areas with unstable or no insurance coverage may be at particular risk for reduced access and use of some health services relative to their counterparts living in metropolitan areas.

Neurologic disorders in Medicaid vs privately insured children and working-age adults

This retrospective, observational study reports health utilization and access patterns of Medicaid recipients for neurologic diseases compared to privately insured individuals seen in 2 hospitals at a single institution in the same time period. We reviewed records of patients and compared demographic characteristics, visit types, neurologic diagnoses, and all-cause mortality, by age group, when seen with Medicaid vs private insurance. Adults insured by Medicaid were more likely to present as inpatients and with life-threatening neurologic disease compared to privately insured patients. Moreover, adult patients presenting with neurologic disease on Medicaid had a higher all-cause mortality rate than privately insured patients. Similar disparities in neurologic disease were not observed in children. The relationship of these findings to patient educational status, household income, comorbidities, and the reasons prompting Medicaid eligibility require additional study.

Healthcare utilization of patients with epilepsy in Yuma County, Arizona: do disparities exist?

The aim of this study was to describe the disparities in healthcare utilization and costs between Hispanic and non-Hispanic patients with seizures or epilepsy. We reviewed the insurance status and healthcare resource utilization data from 2005 to 2008 for all patients with seizures and epilepsy seen at the Yuma Regional Medical Center (YRMC). Charges for medical services provided to Hispanic patients with epilepsy between the ages of 18 and 49 were significantly less than those for non-Hispanic patients with epilepsy (Hispanic: $3167.63 versus non-Hispanic: $5154.36, P<0.001). Taking into account the differences in insurance status, setting of care, and total number of procedures, we still saw a significant difference in charges between the two groups at the outpatient settings. These data differ from currently available data on national and Eastern US Hispanic patients with epilepsy, suggesting that patients in this border community are somehow different from Hispanics elsewhere in the US.

Assessing Systems of Care for US Children with Epilepsy/Seizure Disorder

Background. The proportion of US children with special health care needs (CSHCN) with epilepsy/seizure disorder who receive care in high-quality health service systems was examined. Methodology. We analyzed data for 40,242 CSHCN from the 2009-2010 National Survey of CSHCN and compared CSHCN with epilepsy/seizure disorder to CSHCN without epilepsy/seizure disorder. Measures included attainment rates for 6 federal quality indicators with comparisons conducted using chi square and logistic regression methods. In addition, CSHCN with epilepsy/seizure disorder were compared to CSHCN without epilepsy/seizure disorder on the basis of 14 unmet health care needs. Results. Lower attainment rates for receiving comprehensive care in a medical home and easily accessible community-based services were found for CSHCN with epilepsy/seizure disorder versus CSHCN without epilepsy/seizure disorder (medical home: 32% versus 43%; accessible community-based services: 50% versus 66%, resp.) in unadjusted analyses. Lower adjusted odds for these indicators as well as greater unmet need for specialists, dentistry, prescriptions, therapies, and mental health care were also found for CSHCN with epilepsy/seizure disorder. Conclusions. Further efforts are needed to improve attainment of high-quality health care services for CSHCN with epilepsy/seizure disorders.

Disparities in access to specialized epilepsy care

OBJECTIVE

To examine the impact of individual and community characteristics on access to specialized epilepsy care.

METHODS

This retrospective cross-sectional study analyzed data from the California State Inpatient Sample, the State Ambulatory Surgery Database, and the State Emergency Department Database, that were linked with the 2009 Area Resource File and the location of the National Association of Epilepsy Center's epilepsy centers. The receipt of video-EEG monitoring was measured and used to indicate access to specialized epilepsy care in subjects with persistent seizures, identified as those who had frequent seizure-related hospital admissions and/or ER visits. A hierarchical logistic regression model was employed to assess barriers to high quality care at both individual and contextual levels.

RESULTS

Among 115,632 persons with persistent seizures, individuals who routinely received care in an area where epilepsy centers were located were more likely to have access to specialized epilepsy care (OR: 1.81, 95% CI: 1.20, 2.72). Interestingly, the availability of epilepsy centers did not influence access to specialized epilepsy care in people who had private insurance. In contrast, uninsured individuals and those with public insurance programs including Medicaid and Medicare had significant gaps in access to specialized epilepsy care. Other individual characteristics such as age, race/ethnicity, and the presence of comorbid conditions were also associated with disparities in access to specialized care in PWE.

CONCLUSION

Both individual and community characteristics play substantial roles in access to high quality epilepsy care. Policy interventions that incorporate strategies to address disparities at both levels are necessary to improve access to specialized care for PWE.

Defining incident cases of epilepsy in administrative data

PURPOSE

To determine the minimum enrollment duration for identifying incident cases of epilepsy in administrative data.

METHODS

We performed a retrospective dynamic cohort study using Ohio Medicaid data from 1992 to 2006 to identify a total of 5037 incident epilepsy cases who had at least 1 year of follow-up prior to epilepsy diagnosis (epilepsy-free interval). The incidence for epilepsy-free intervals from 1 to 8 years, overall and stratified by pre-existing disability status, was examined. The graphical approach between the slopes of incidence estimates and the epilepsy-free intervals was used to identify the minimum epilepsy-free interval that minimized misclassification of prevalent as incident epilepsy cases.

RESULTS

As the length of epilepsy-free interval increased, the incidence rates decreased. A graphical plot showed that the decline in incidence of epilepsy became nearly flat beyond the third epilepsy-free interval.

CONCLUSION

The minimum of 3-year epilepsy-free interval is needed to differentiate incident from prevalent cases in administrative data. Shorter or longer epilepsy-free intervals could result in over- or under-estimation of epilepsy incidence.

Surveillance of epilepsy and prevention of epilepsy and its sequelae: lessons from the Institute of Medicine report

PURPOSE OF REVIEW

The Institute of Medicine's report, Epilepsy across the Spectrum: Promoting Health and Understanding contains two recommendations for increased epilepsy surveillance and one recommendation on prevention in epilepsy. Evidence supporting these recommendations and the information that can be gained from them is reviewed.

RECENT FINDINGS

Existing epilepsy surveillance data are inadequate to address factors such as seizure type, syndrome, socioeconomic status, and race/ethnicity in large representative populations. Ongoing surveillance is needed with follow-up of people with epilepsy for adverse epilepsy outcomes so that interventions to prevent these outcomes can be formulated. Substantial barriers to receiving appropriate medical care exist for minorities and the uninsured with epilepsy; more information on these differences and their causes is needed. Lack of standardized study methods and data sources results in differences in medical service costs, care and treatments, and limited information on cost-effectiveness of specific healthcare services for epilepsy.

SUMMARY

Future epilepsy surveillance should track incidence and prevalence over time, access to epilepsy care, direct and indirect costs, and the cost-effectiveness of treatment. Prevention efforts to decrease the occurrence of epilepsy and improve access and effectiveness of care will ameliorate adverse outcomes in epilepsy.

Medicaid status is associated with higher complication rates after spine surgery

STUDY DESIGN

Multivariate analysis of prospectively collected registry data.

OBJECTIVE

To determine the effect of payor status on complication rates after spine surgery.

SUMMARY OF BACKGROUND DATA

Understanding the risk of perioperative complications is an essential aspect in improving patient outcomes. Previous studies have looked at complication rates after spine surgery and factors related to increased perioperative complications. In other areas of medicine, there has been a growing body of evidence gathered to evaluate the role of payor status on outcomes and complications. Several studies have found increased complication rates and inferior outcomes in the uninsured and Medicaid insured.

METHODS

The Spine End Results Registry (2003-2004) is a collection of prospectively collected data on all patients who underwent spine surgery at our 2 institutions. Extensive demographic data, including payor status, and medical information were prospectively recorded as described previously by Mirza et al. Medical complications were defined in detail a priori and were prospectively recorded for at least 2 years after surgery. Using univariate and multivariate analysis, we determined risk of postoperative medical complications dependent on payor status.

RESULTS

A total of 1591 patients underwent spine surgery in 2003 and 2004 that met our criteria and were included in our analysis. With the multivariate analysis and by controlling for age, patients whose insurer was Medicaid had a 1.68 odds ratio (95% confidence interval: 1.23-2.29; P = 0.001) of having any adverse event when compared with the privately insured.

CONCLUSION

After univariate and multivariate analyses, Medicaid insurance status was found to be a risk factor for postoperative complications. This corresponds to an ever-growing body of medical literature that has shown similar trends and raises the concern of underinsurance.

Applying evidence to patient care: from population health to individual patient values

What are the health status and health needs of people with epilepsy? How do clinicians and patients choose between alternative interventions for the same condition? Are health interventions used effectively in the community, and do they improve health? How can we translate findings from regulatory clinical trials to the real world? These and similar questions are the subject of applied translational research. This evolving and broad-ranging area of research involves the application of basic sciences such as epidemiology, biostatistics, economics, and behavioral science to the assessment of health, health interventions, and outcomes. However, despite its palpable importance, applied translational research remains underfunded and underutilized. Using their own innovative research as a prototype, two young and promising investigators provide insights not only into the enormous potential but also the gaps and hurdles of two specific areas of applied translational research, i.e., clinical decision analysis and health services research. The message is clear that if we are to understand and improve the health of people with epilepsy in clinics, hospitals, and communities, we must substantially increase research capacity to address the many gaps that thwart our progress in applied research in epilepsy.

Research implications of the Institute of Medicine Report, Epilepsy Across the Spectrum: Promoting Health and Understanding

In March 2012 the Institute of Medicine (IOM) released the report, Epilepsy Across The Spectrum: Promoting Health and Understanding. This report examined the public health dimensions of the epilepsies with a focus on the following four areas: public health surveillance and data collection and integration; population and public health research; health policy, health care, and human services; and education for providers, people with epilepsy and their families, and the public. The report provided recommendations and research priorities for future work in the field of epilepsy that relate to increasing the power of data on epilepsy; prevention of epilepsy; improving health care for people with epilepsy; improving health professional education about epilepsy; improving quality of life for people with epilepsy; improving education about epilepsy for people with epilepsy and families; and raising public awareness about epilepsy. For this article, the authors selected one research priority from each of the major chapter themes in the IOM report: expanding and improving the quality of epidemiologic surveillance in epilepsy; developing improved interventions for people with epilepsy and depression; expanding early identification/screening for learning impairments in children with epilepsy; evaluating and promoting effective innovative teaching strategies; accelerating research on the identification of risk factors and interventions that increase employment and improve quality of life for people with epilepsy and their families; assessing the information needs of people with epilepsy and their families associated with epilepsy-related risks, specifically sudden unexpected death in epilepsy; and developing and conducting surveys to capture trends in knowledge, awareness, attitudes, and beliefs about epilepsy over time and in specific population subgroups. For each research priority selected, examples of research are provided that will advance the field of epilepsy and improve the lives of people with epilepsy. The IOM report has many other research priorities for researchers to consider developing to advance the field of epilepsy and better the lives of people with epilepsy.