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Miller JS, Oladele F, McAfee D, Adereti CO, Theodore WH, Akinsoji EO. Disparities in Epilepsy Diagnosis and Management in High-Income Countries: A Review of the Literature. Neurol Clin Pract 2024; 14:e200259. [PMID: 38585438 PMCID: PMC10996906 DOI: 10.1212/cpj.0000000000200259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/20/2023] [Indexed: 04/09/2024]
Abstract
Purpose of Review Currently, an estimated 3.4 million people in the United States live with epilepsy. Previous studies have identified health disparities associated with race/ethnicity, socioeconomic status (SES), sex, insurance status, and age in this population. However, there has been a dearth of research addressing these disparities. We performed a literature review of articles published between 2010 and 2020 pertaining to health disparities in people with epilepsy (PWE), identified key factors that contribute to gaps in their care, and discussed possible solutions. Recent Findings Health disparities in prevalence, treatment access, time to diagnosis, health care delivery and engagement, and clinical outcomes were identified among individuals who were either of low SES, rural-based, uninsured/underinsured, older patients, patients of color, or female sex. Summary Disparities in care for PWE continue to persist. Greater priority should be placed on addressing these gaps intricately tied to sociodemographic factors. Reforms to mitigate health disparities in PWE are necessary for timely diagnosis, effective treatment, and positive long-term outcomes.
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Affiliation(s)
- Joseph S Miller
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - Folake Oladele
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - Darrian McAfee
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - Christopher O Adereti
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - William H Theodore
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
| | - Elizabeth O Akinsoji
- Ohio University Heritage College of Osteopathic Medicine (JSM), Dublin, OH; Memorial Sloan Kettering Cancer Center (FO), New York; University of Maryland School of Medicine (DM), Baltimore, MD; Ross University School of Medicine (COA); National Institute of Neurological Disorders and Stroke (WHT), National Institutes of Health, Bethesda, MD; and Department of Neurology (EOA), Emory University School of Medicine, Atlanta, GA
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Ghebrehiwet M, Cox K, Nees D, Dunford B, Jacobsen SM, Bacani R, Vassar M. Inequities in Epilepsy: A Scoping Review. Neurol Clin Pract 2023; 13:e200211. [PMID: 37795499 PMCID: PMC10547471 DOI: 10.1212/cpj.0000000000200211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 08/21/2023] [Indexed: 10/06/2023]
Abstract
Objectives The objective of this study was to complete a scoping review of current literature surrounding health inequities in epilepsy while providing recommendations for future research. Methods During July 2022, we searched MEDLINE and Ovid Embase to find published articles pertaining to epilepsy and health inequities. Initially, authors received training. Authors then screened, and data were extracted in a masked duplicate manner. Studies published within the time frame of 2011-2021 in all countries were deemed appropriate. We screened 5,325 studies for titles and abstracts and then 56 studies for full text. We evaluated the inequities of race/ethnicity, sex or gender, income, occupation status, education level, under-resourced/rural population, and LGBTQ+. To summarize the data and descriptive statistics of our study, we used Stata 17.0 (StataCorp, LLC, College Station, TX). Results We obtained a sample size of 45 studies for study inclusion. The most reported health inequities were income (18/45, 40.0%), under-resourced/rural population (15/45, 33.3%), and race/ethnicity (15/45, 33.3%). The least reported health inequity was LGBTQ+ (0/45, 0.0%). Discussion The findings of our study suggest that gaps exist in literature concerning epilepsy and inequities. The inequities of income status, under-resourced/rural population, and race/ethnicity were examined the most, while LGBTQ+, occupation status, and sex or gender were examined the least. With the ultimate goal of more equitable and patient-centered care in mind, it is vital that future studies endeavor to fill in these determined gaps.
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Affiliation(s)
- Merhawit Ghebrehiwet
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Katherine Cox
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Danya Nees
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Bryan Dunford
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Samuel M Jacobsen
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Rigel Bacani
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
| | - Matt Vassar
- Office of Medical Student Research (MG, KC, DN, BD, SMJ, RB, MV); and Department of Psychiatry and Behavioral Sciences (MV), Oklahoma State University Center for Health Sciences, Tulsa
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Gotlieb EG, Blank L, Willis AW, Agarwal P, Jette N. Health equity integrated epilepsy care and research: A narrative review. Epilepsia 2023; 64:2878-2890. [PMID: 37725065 DOI: 10.1111/epi.17728] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 07/11/2023] [Accepted: 07/26/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND With the unanimous approval of the Intersectoral Global Action Plan on epilepsy and other neurological disorders by the World Health Organization in May 2022, there are strong imperatives to work towards equitable neurological care. AIMS Using epilepsy as an entry point to other neurologic conditions, we discuss disparities faced by marginalized groups including racial/ethnic minorities, Americans living in rural communities, and Americans with low socioeconomic status. MATERIALS AND METHODS The National Institute on Minority Health Disparities Research Framework (NIMHD) was used to conduct a narrative review through a health equity lens to create an adapted framework for epilepsy and propose approaches to working towards equitable epilepsy and neurological care. RESULTS In this narrative review, we identified priority populations (racial and ethnic minority, rural-residing, and low socioeconomic status persons with epilepsy) and outcomes (likelihood to see a neurologist, be prescribed antiseizure medications, undergo epilepsy surgery, and be hospitalized) to explore disparities in epilepsy and guide our focused literature search using PubMed. In an adapted NIMHD framework, we examined individual, interpersonal, community, and societal level contributors to health disparities across five domains: (1) behavioral, (2) physical/built environment, (3) sociocultural, (4) environment, and (5) healthcare system. We take a health equity approach to propose initiatives that target modifiable factors that impact disparities and advocate for sustainable change for priority populations. DISCUSSION To improve equity, healthcare providers and relevant societal stakeholders can advocate for improved care coordination, referrals for epilepsy surgery, access to care, health informatics interventions, and education (i.e., to providers, patients, and communities). More broadly, stakeholders can advocate for reforms in medical education, and in the American health insurance landscape. CONCLUSIONS Equitable healthcare should be a priority in neurological care.
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Affiliation(s)
- Evelyn G Gotlieb
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Leah Blank
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population, Health Science and Policy and Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Allison W Willis
- Departments of Neurology and Biostatistics, Epidemiology and Informatics, University of Pennsylvania
- Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Parul Agarwal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population, Health Science and Policy and Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Nathalie Jette
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Population, Health Science and Policy and Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Szaflarski M. Racialized Inequities in Epilepsy Burden and Treatment. Neurol Clin 2022; 40:821-830. [DOI: 10.1016/j.ncl.2022.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Gupta SK, Margolis SA, Grant AC, Gonzalez JS, Nakhutina L. Relationships among illness representations and depressive symptom severity in predominantly African-American and Caribbean-American people with epilepsy. Clin Neuropsychol 2021; 36:462-478. [PMID: 34027793 DOI: 10.1080/13854046.2021.1923802] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective: Depression is the most common psychiatric comorbidity among people with epilepsy (PWE) and tends to be more prevalent among people of color (POC) and those with intractable seizures. However, the extent to which illness-related perceptions are associated with depressive symptom severity among POC with intractable seizures is unclear. Method: This cross-sectional study examined relationships among illness representations and self-rated depressive symptoms in 55 PWE (M Age = 41; 61.8% female) with intractable seizures (M seizures per month = 2) who identified as Black/African-American (52.7%), Black/Caribbean-American (27.3%), and/or Hispanic/Latino (21.8%). Epilepsy-related illness perceptions were assessed with the Illness Perception Questionnaire-Revised and depression was measured via the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E). Results: Nearly half of the sample (41.8%) scored above the NDDI-E depression cut-off. PWE endorsing more severe depressive symptoms indicated that their epilepsy had more negative consequences, was hard to comprehend, was insufficiently controlled by treatment, and had a negative emotional impact (p's ≤ 0.02). Controlling for sex, these four illness representations accounted for 48% of the variance in depression severity. Interestingly, participants with probable major depressive episodes were more likely to endorse several psychological causes of seizures compared to non-depressed PWE. Conclusions: Worse depression symptom severity was associated with negative illness perceptions and a tendency to attribute one's epilepsy to psychological causes. Future research is needed to understand how the relationship between negative illness perceptions and depression symptoms unfold over time and whether interventions aimed at modifying illness representations reduce psychological distress in diverse PWE.
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Affiliation(s)
- Sugandha K Gupta
- Graduate Center, City University of New York, Psychology, New York, NY, USA
| | - Seth A Margolis
- Alpert Medical School, Brown University, Providence, RI, USA
| | - Arthur C Grant
- Downstate Medical Center, State University of New York, New York, NY, USA
| | - Jeffrey S Gonzalez
- Ferkauf Graduate School of Psychology, Yeshiva University, New York, NY, USA.,Albert Einstein College of Medicine, Bronx, New York, NY, USA
| | - Luba Nakhutina
- Downstate Medical Center, State University of New York, New York, NY, USA
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Teagarden DL, Morton ML, Janocko NJ, Groover O, Villarreal HK, Evans L, Drane DL, Karakis I. Socioeconomic disparities in patients with psychogenic nonepileptic seizures and their caregivers. Epilepsy Behav 2020; 110:107160. [PMID: 32493610 DOI: 10.1016/j.yebeh.2020.107160] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE There is no information on disparities of patients with psychogenic nonepileptic seizures (PNES) and their caregivers. The objective of this exploratory study is to compare patients with PNES and caregivers with low socioeconomic status (SES) with those of high SES for disparities in healthcare use, seizures, medication adverse effects, psychosocial impact, and knowledge about epilepsy. METHODS Patients with PNES and caregivers completed surveys about the aforementioned outcomes during their Epilepsy Monitoring Unit (EMU) admission. Associations were evaluated using SES as a binary independent variable and the patient- and caregiver-related outcomes as dependent variables. RESULTS Forty-three patients and 28 caregivers were recruited. The majority of patients were on average 36 years old, single women, unemployed, with some college education. The majority had PNES for 8 years averaging 20 seizures per month and were maintained on ≥2 antiepileptic drugs (AEDs) prior to their EMU admission. Most caregivers were first-degree relatives with a mean age of 43 years, married employed women of higher educational attainment, typically cohabitating with the patients. Low SES patients showed poorer knowledge about epilepsy (p < 0.0001) and higher anxiety levels (p = 0.03). Conversely, high SES patients demonstrated poorer social functioning (p = 0.04). High SES caregivers showed higher caregiving burden (p = 0.01). CONCLUSION There are noteworthy disparities in patients with PNES of different SES and their caregivers. Identification of those disparities is a critical step in the creation of appropriate interventions to address them.
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Affiliation(s)
- Diane L Teagarden
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Matthew L Morton
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Nicholas J Janocko
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Olivia Groover
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Hannah K Villarreal
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Latasha Evans
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Daniel L Drane
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA; Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA; Department of Neurology, University of Washington, Seattle, WA, USA
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
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Recognition of Infantile Spasms Is Often Delayed: The ASSIST Study. J Pediatr 2017; 190:215-221.e1. [PMID: 29144248 DOI: 10.1016/j.jpeds.2017.08.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 07/07/2017] [Accepted: 08/03/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To characterize and quantify diagnostic and treatment delay among children with infantile spasms, and to estimate the developmental impact of this delay. STUDY DESIGN In this cohort study, we surveyed the parents of 100 patients with infantile spasms about their experiences with diagnosis and treatment, and ascertained medical and sociodemographic factors potentially related to care of these infants. We specifically determined the latency to first visit an "effective provider," defined as a provider who identified infantile spasms, and prescribed an appropriate first-line treatment, namely adrenocorticotropic hormone, corticosteroids, or vigabatrin. Time to the first visit to an effective provider was evaluated using Cox proportional hazards regression. RESULTS The median time from the onset of infantile spasms to first visit with an effective provider was 24.5 days. Only 29% of patients were evaluated by an effective provider within 1 week of infantile spasms onset. The time to first effective provider visit was associated with parental language preference, but with no other sociodemographic characteristics. Parents' suspicions that "something is wrong" were often discounted by healthcare providers, and survey respondents frequently reported that pediatricians and neurologists were unfamiliar with infantile spasms. CONCLUSION This study demonstrates that substantial delay (ie, >1 week) in appropriate care is common, and suggests that the poor awareness of infantile spasms among healthcare providers is at least partly responsible for preventable and potentially significant delays in treatment.
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Fantaneanu TA, Hurwitz S, van Meurs K, Llewellyn N, O'Laughlin KN, Dworetzky BA. Racial differences in Emergency Department visits for seizures. Seizure 2016; 40:52-6. [PMID: 27344498 DOI: 10.1016/j.seizure.2016.06.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 05/20/2016] [Accepted: 06/07/2016] [Indexed: 01/14/2023] Open
Abstract
PURPOSE Seizures are a common reason for visiting the Emergency Department (ED). There is a growing body of literature highlighting disparities in seizure care related to race and ethnicity. Our goal was to identify racial and clinical characteristics of patients presenting to the ED with seizures and to determine factors associated with repeat ED visits for seizure. METHODS This was a retrospective study evaluating patients presenting with seizure as the primary reason for their ED visit between 01/01/2008 and 12/31/2008. Clinical data were collected from the electronic medical record (EMR) and compared between black and white patients and between patients with single and repeat ED seizure visits. Statistically significant variables were introduced in a logistic regression analysis with repeat ED visits as outcome. RESULTS Of 38, 879 ED visits, 559 recorded 'seizure' as the primary reason for the visit. Compared to white patients (N=266), black patients (N=102) were more likely to have non-private insurance (p=0.005), less likely to have evidence of regular ambulatory care (p=0.02) and were more likely to have multiple visits within the calendar year (p=0.005). Black patient visits were more likely to have missed or ran out of antiepileptic drugs (AED) as the precipitant for their ED visit (p<0.001). CONCLUSION Clinical factors differed between black and white patients presenting to the ED for seizure care. Black patients were more likely to have multiple seizure visits to the ED when compared to white patients. This may suggest a disparity in access to care related to race between these two groups.
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Affiliation(s)
| | - Shelley Hurwitz
- Department of Medicine, Brigham and Women's Hospital, United States.
| | | | | | - Kelli N O'Laughlin
- Department of Emergency Medicine, Harvard Medical School, Brigham and Women's Hospital, United States.
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Szaflarski M. Social determinants of health in epilepsy. Epilepsy Behav 2014; 41:283-9. [PMID: 24998313 DOI: 10.1016/j.yebeh.2014.06.013] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 06/05/2014] [Accepted: 06/07/2014] [Indexed: 10/25/2022]
Abstract
Social factors have been identified as key drivers of epilepsy care, outcomes, and disparities, but there is a limited understanding of what these factors are and how they translate into disparities. This targeted review provides an overview of the social determinants of health framework and applies this perspective to the literature about social and psychosocial factors in epilepsy; a social determinants of health--epilepsy model is proposed. The key social determinants of health in epilepsy include socioeconomic status, race/ethnicity, age, and gender. For example, low socioeconomic status and minority status have been associated with a higher risk of epilepsy, more hospitalizations and emergency room visits (versus neurology services), antiepileptic drug nonadherence, and a lower rate of epilepsy surgery. Such differences in care/treatment and outcomes translate into health disparities, many of which are considered unjust (inequitable) and modifiable through social action. Other social determinants of health include structural and sociocultural contextual conditions (e.g., health economy, policy, and social stigma/discrimination) and mediating mechanisms including material (e.g., housing), behavioral/biological (e.g., adherence), psychosocial (e.g., perceived stigma), and health system (e.g., access) factors. There are complex relationships among social determinants of health in epilepsy, which remain poorly understood and hamper efforts to address and eliminate disparities in epilepsy care and outcomes. Further empirical work grounded in sound theory and robust methodologies is needed to identify points of intervention and design effective and socially acceptable solutions to any pervasive disparities in epilepsy.
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Affiliation(s)
- Magdalena Szaflarski
- Department of Sociology, University of Alabama at Birmingham, HHB 460H, 1720 2nd Ave South, Birmingham, AL 35294-1152, USA.
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