Welfare cost of childhood- and adolescent-onset epilepsy: A controlled national study

Economic Evaluation of anti-epileptic Medicines for Autistic Children with Epilepsy

We examine the cost-effectiveness of treating epilepsy with anti-epileptic medicines in autistic children, looking at impacts on healthcare providers (in England, Ireland, Italy and Spain) and children's families (in Ireland). We find carbamazepine to be the most cost-effective drug to try first in children with newly diagnosed focal seizures. For England and Spain, oxcarbazepine is the most cost-effective treatment when taken as additional treatment for those children whose response to monotherapy is suboptimal. In Ireland and Italy, gabapentin is the most cost-effective option. Our additional scenario analysis presents the aggregate cost to families with autistic children who are being treated for epilepsy: this cost is considerably higher than healthcare provider expenditure.

Safety and feasibility of an intensive epilepsy nurse-based treatment course

PURPOSE

To determine safety, feasibility and patient satisfaction of an epilepsy nurse-based treatment course with frequent contacts and changes of anti-epileptic treatment provided by supervised anti-epileptic drug (AED) prescribing epilepsy nurses.

METHODS

Regular prescheduled clinical contacts with a neurologist to adjust AED treatment were largely substituted by on-demand contacts with epilepsy nurses with the delegated right to adapt AED within predefined limits. To secure safety, electronic medical files of patients with 6 or more contacts with epilepsy nurses were retrospectively analysed for clinical characteristics, safety measures and seizure frequency before/after the intensive treatment course and patients were asked to complete a questionnaire about treatment satisfaction.

RESULTS

Between January 1^st 2016 and 31^st December 2018, 2721 patients were treated by epilepsy nurses (2561 ambulatory controls, 8690 phone contacts). 617 patients received an intensive treatment course (six or more contacts in the observation period, range: 6-65) with an average length of 24.3 months. The average number of AED tried was 3.4. In patients with ongoing seizures (n = 310), 165 (53.2 %) reported an improvement of seizure frequency by 50 % or more. Seizure frequency fell from 4.4 to 2.4 days with seizures/months (p < 0.001). The epilepsy-related hospitalization rate was 0.86/patient; 27 episodes with status epilepticus occurred in 21 patients, three hospitalizations were due to severe side effects. There were no fatal complications. No hospitalization was related to the intensive treatment course by prescribing epilepsy nurses. The overall patients' satisfaction was high.

CONCLUSION

Intensive epilepsy treatment facilitated by epilepsy nurses was safe and associated with high patient accept and improvement of seizure frequency.

Long-term health and socioeconomic outcome of obstructive sleep apnea in children and adolescents

BACKGROUND

There is limited information about the long-term outcome of obstructive sleep apnea (OSA) diagnosed in children and adolescents for educational and social factors. Here, we estimate the long-term socioeconomic outcome and health care costs of OSA.

METHODS

The historical case-control cohort study included Danish individuals with OSA diagnosed in childhood or adolescence between 1994 and 2015. Health care costs and socioeconomic data were obtained from nationwide administrative and health registers. A total of 5419 were diagnosed during this period; of these we traced 1004 patients who we compared with 4085 controls (mean index age, 10.2 years; Standard Deviation (SD), 5.6 years) until the age of 20 years. Controls were matched for age, gender, and residency.

RESULTS

Comparing the OSA patient and control groups at age 20 years we found: 1) lower parental educational level; 2) significantly lower educational level also after adjustment for parental educational level; 3) lower school grade-point averages; 4) lower employment rate and lower income, which was not fully compensated when transfer payments were considered; and 5) patients' initial health care costs were higher due to higher morbidity. Patients showed higher mortality rates than controls (Hazard Ratio (HR) = 7.63, 95% CI = 4.87-11.95, P < 0.001).

CONCLUSIONS

OSA in children and adolescent is associated with a significant influence on morbidity, mortality, educational level, grading, social outcome, and welfare consequences.

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.

Hospital service utilization trajectories of individuals living with epilepsy in New South Wales, Australia, 2012-2016: A population-based study

OBJECTIVES

This study aimed to examine five-year trajectories of hospital service utilization among individuals living with epilepsy in New South Wales (NSW), Australia, and to identify factors predictive of trajectory group membership.

METHODS

This study used group-based trajectory modeling of hospital admissions over a five-year period for individuals living with epilepsy who had an epilepsy-related hospitalization during 1 January 2012 and 31 December 2012 in NSW, Australia (n = 5762).

RESULTS

The analysis revealed the following five distinct hospital service utilization trajectory groups: "one-off users" (Group 1; 22.9%), "low-chronic users" (Group 2; 47.1%), "moderate-declining users" (Group 3; 10.3%), "moderate-chronic users" (Group 4; 18.3%), and "high-chronic users" (Group 5; 1.5%). There were key features that defined trajectory group membership, in particular the relative proportions of group members with chronic health conditions, other comorbid conditions, refractory epilepsy, and status epilepticus. For instance, "high-chronic users" (Group 5) had higher proportions of individuals with chronic health conditions (34.8%) and refractory epilepsy (19.1%); "moderate-declining users" (Group 3) had higher proportions of individuals with chronic health conditions (35.1%) and status epilepticus (9.8%); and "low-chronic users" (Group 2) had the lowest proportion of individuals with chronic health conditions.

CONCLUSION

It is important to gain a better understanding of hospital service utilization among individuals living with epilepsy. This research has identified trajectory groups of hospital service utilization profiles of individuals living with epilepsy. Identification of predictors of trajectory group membership allows targeting of strategies to reduce hospital admissions, inform healthcare service delivery, and improve the health and wellbeing of individuals living with epilepsy.

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.

Long-term health and socioeconomic consequences of childhood and adolescent onset of meningococcal meningitis

We estimated the long-term socioeconomic consequences and health care costs of Neisseria meningitidis meningitis (NM). The prospective cohort study included Danish individuals with onset of NM in childhood and adolescence, diagnosed between 1980 and 2009. Health care costs and socioeconomic data were obtained from nationwide administrative and health registers. Two thousand nine hundred two patients were compared with 11,610 controls matched for age, gender, and other sociodemographic characteristics. In the follow-up analysis at the age of 30 years, 1028 patients were compared with 4452 controls. We found that (1) NM caused increased mortality at disease onset, but after adequate treatment, the mortality rate was similar to that of the general population; (2) neurological and eye diseases were more frequently observed in patients; (3) patients had significantly lower grade-point averages; (4) patients had lower income even when transfer payments were taken into account; and (5) patients' initial health care costs were elevated.Conclusion: NM has significant influence on mortality, morbidity, education, and income. We suggest that the management of patients with previous meningococcal meningitis should focus on early educational and social interventions to improve social and health outcomes. What is known: • Meningococcal meningitis is a severe infectious disease affecting children and adolescents with high rates of mortality and complications. What is new: • Meningococcal meningitis causes increased mortality at disease onset, but after adequate treatment the mortality rate is similar to that of the general population. • Meningococcal meningitis in childhood and adolescence has a major long-term effect on morbidity, health care costs, education, employment, and income.

Epilepsy genetics: Current knowledge, applications, and future directions

The rapid pace of disease gene discovery has resulted in tremendous advances in the field of epilepsy genetics. Clinical testing with comprehensive gene panels, exomes, and genomes are now available and have led to higher diagnostic rates and insights into the underlying disease processes. As such, the contribution to the care of patients by medical geneticists, neurogeneticists and genetic counselors are significant; the dysmorphic examination, the necessary pre- and post-test counseling, the selection of the appropriate next-generation sequencing-based test(s), and the interpretation of sequencing results require a care provider to have a comprehensive working knowledge of the strengths and limitations of the available testing technologies. As the underlying mechanisms of the encephalopathies and epilepsies are better understood, there may be opportunities for the development of novel therapies based on an individual's own specific genotype. Drug screening with in vitro and in vivo models of epilepsy can potentially facilitate new treatment strategies. The future of epilepsy genetics will also probably include other-omic approaches such as transcriptomes, metabolomes, and the expanded use of whole genome sequencing to further improve our understanding of epilepsy and provide better care for those with the disease.

Use of primary healthcare for persons with epilepsy

INTRODUCTION

In Denmark, care and treatment related to epilepsy primarily takes place at specialized hospital departments (neurology and pediatrics). The general practitioner (GP) in contrast is the primary contact and acts as a gatekeeper to the healthcare system for other disorders. The aim of the present study was to describe the utilization of services provided by the GP for children with epilepsy before and after diagnosis of epilepsy and to compare it with that of children without epilepsy.

METHODS

All live born children born in Denmark between 1st of January 1996 and 1st of December 2013 were identified in the Danish National Patient Registry. Information about number and type of contact to the general practitioner was obtained from the Health Insurance Service Register. Information about epilepsy was obtained from the Danish National Patient Registry (n=10,062). For each child with epilepsy, we sampled 10 children without an epilepsy diagnosis matched on sex and age at the time of diagnosis (n=100,620). Children were followed up until 31st of December 2013. Multiple negative binomial regression analysis adjusting for relevant confounders was used to estimate the association between epilepsy and the use of GPs both before and after the time of epilepsy diagnosis.

RESULTS

Children with epilepsy had a higher utilization of services provided by the GP after the diagnosis of epilepsy compared with children without epilepsy (incidence rate ratio (IRR): 1.64 (1.61-1.67)). The IRR for any contacts stayed relatively stable during the follow-up period, whereas the IRR for face-to-face contacts tended to decline and phone contacts tended to increase. The more frequent GP contacts in children with epilepsy were also evident before the time of diagnosis and for both sexes and in all age groups. For the specific services provided, children with epilepsy more often had a blood sample taken and more urine stix and CRP tests performed during the first years following diagnosis.

CONCLUSION

Children with epilepsy have a higher use of services provided by the GP both before and after the epilepsy diagnosis compared with children without epilepsy. This is likely due to a higher prevalence of comorbid conditions in children with epilepsy as well as consequences of the underlying condition.

Nationwide Healthcare utilization among children with epilepsy in the United States: 2003-2014

BACKGROUND

Epilepsy is particularly frequent among children, yet updated and nationwide healthcare utilization estimates are scanty in the United States.

OBJECTIVE

To analyze healthcare utilization among children with epilepsy.

METHODS

Data on children (≤17-year-old) were extracted from the Medical Expenditure Panel Survey (MEPS) 2003-2014. Epilepsy was identified using the clinical classification code 83. Healthcare utilization (Inpatient admission, outpatient visits, prescription medication including refill, emergency room visits, and home health provider visits) was compared between children with epilepsy and those without epilepsy. A negative binomial model was used to assess the relationship between epilepsy and healthcare utilizations accounting for the influence of extraneous factors.

RESULTS

In all, a weighted 457,873 children (0.84%) had epilepsy in United States. The unadjusted proportion and the mean annual number of health care service utilization were higher in children with epilepsy compared to those without epilepsy. Children with epilepsy had almost 3.3 more outpatient visits (95% CI: 2.281-4.274), 7.9 more medication prescriptions including refills (95% CI: 6.058-9.662), nearly 0.4 more emergency department visits (95% CI: 0.278-0.438) and nearly 12 more home health provider visits (95% CI: 1.988-21.756) than those without epilepsy. The adjusted marginal effect of epilepsy on inpatient admission was not statistically significant.

CONCLUSION

unadjusted and adjusted healthcare utilization is considerably higher in children with epilepsy compared to those without epilepsy in the United States with heterogeneity across individual services.

Morbidity and mortality of childhood- and adolescent-onset epilepsy: A controlled national study

PURPOSE

Epilepsy is associated with significant morbidities and mortality. We aimed to evaluate the 30-year morbidities and mortality in a national group of patients after a first diagnosis of epilepsy.

METHODS

From the Danish National Patient Registry (NPR), in total, 3123 patients with epilepsy aged 0-5years and 5018 patients aged 6-20years diagnosed in 1998-2002 were identified and compared with, respectively, 6246 and 10,036 persons matched for age, gender, and place of living with randomly chosen citizens from the Danish Civil Registration System Statistics. In the NPR, all morbidities in the following 30years were grouped into major WHO disease classes.

KEY FINDINGS

Patients with epilepsy had significantly higher rates of comorbidities including almost all health-related comorbidities compared with controls. Mortality rates were elevated: the hazard ratio (5%; 95% CI) was 14.46 (11.8; 17.7, p<0.001) and 5.58 (4.9; 6.4, P<0.001) for patients aged 0-5years and 6-20years at first diagnosis of epilepsy, respectively.

SIGNIFICANCE

Epilepsy is associated with significant comorbidities and mortality including all health care domains, especially among persons who were young at the onset of epilepsy.