Innovative approaches reaching underserved and rural communities to improve epilepsy care: A review of the methodology of the Connectors Project

Hospital EEG Capability and Associations With Interhospital Transfer in Status Epilepticus

Background and Objectives

EEG is widely recommended for status epilepticus (SE) management. However, EEG access and use across the United States is poorly characterized. We aimed to evaluate changes in inpatient EEG access over time and whether availability of EEG is associated with interhospital transfers for patients hospitalized with SE.

Methods

We performed a cross-sectional study using data available in the National Inpatient Sample data set from 2012 to 2018. We identified hospitals that used continuous or routine EEG during at least 1 seizure-related hospitalization in a given year using ICD-9 and ICD-10 procedure codes and defined these hospitals as EEG capable. We examined annual change in the proportion of hospitals that were EEG capable during the study period, compared characteristics of hospitals that were EEG capable with those that were not, and fit multivariable logistic regression models to determine whether hospital EEG capability was associated with likelihood of interhospital transfer.

Results

Among 4,550 hospitals in 2018, 1,241 (27.3%) were EEG capable. Of these, 1,188 hospitals (95.7%) were in urban settings. From 2012 to 2018, the proportion of hospitals that were EEG capable increased in urban settings (30.5%-41.1%, Mann-Kendall [M-K] test p < 0.001) and decreased in rural settings (4.0%-3.2%, M-K p = 0.026). Among 130,580 patients hospitalized with SE, 80,725 (61.8%) presented directly to an EEG-capable hospital. However, EEG use during hospitalization varied from 8% to 98%. Initial admission to a hospital without EEG capability was associated with 22% increased likelihood of interhospital transfer (adjusted RR 1.22, [95% CI, 1.09-1.37]; p < 0.01). Among those hospitalized at an EEG-capable hospital, patients admitted to hospitals in the lowest quintile of EEG volume were more than 2 times more likely to undergo interhospital transfer (adjusted RR 2.22, [95% CI 1.65-2.93]; p < 0.001).

Discussion

A minority of hospitals are EEG capable yet care for most patients with SE. Inpatient EEG use, however, varies widely among EEG-capable hospitals, and lack of inpatient EEG access is associated with interhospital transfer. Given the high incidence and cost of SE, there is a need to better understand the importance and use of EEG in this patient population to further organize inpatient epilepsy systems of care to optimize outcomes.

What is the price of residence in rural areas for patients with epilepsy?

INTRODUCTION

We aimed to investigate the effects of the urban or rural dwelling of patients with epilepsy living in Giresun on their use of health services, quality of life, and self-efficacy.

METHODS

In this cross-sectional study, patients with epilepsy who were admitted to the neurology outpatient clinic between January 2022 and August 2022 were evaluated. All the participants were individually interviewed to complete the Epilepsy Self-Efficacy Scale (ESES) and Quality of Life in Epilepsy Inventory (QOLIE-10) questionnaire. The frequency of admission to the emergency department, neurology outpatient clinic, and general practitioner clinic where the primary reason for the visit was epilepsy in the last year was determined using the hospital database.

RESULTS

This study was composed of 109 patients. The rural dwelling was found in 45% of the participants. The mean age of seizure onset was significantly lower in patients dwelling in rural areas Mean GP and ED visits didn't differ according to dwelling. On the other hand, mean neurology outpatient clinic visits were significantly lower in patients living in rural areas. The QOLIE-10 didn't differ according to the dwelling. However, lower ESES results were obtained in patients living in rural areas.

CONCLUSION

This study shows that there is a disparity in neurologist visits among patients with epilepsy dwelling in rural areas. Furthermore, lower ESES scores were found in these patients. Educational interventions should be addressed particularly to the patients dwelling in rural areas to strengthen self-efficacy, and fill the gaps for the shortage of health personnel and qualified health care.

Comparison of care accessibility, costs, and quality with face-to-face and telehealth epilepsy clinic visits

During the COVID-19 pandemic, restrictions on reimbursement for telehealth visits were lifted and this visit type was suddenly available to patients around the United States of America. Telehealth visits offer potential cost savings for patients and families, which may vary by region of the world studied. Also, aggressiveness of the care patients receive may differ, and patients or families may be more likely to choose one visit type over another based on seizure control. This is a prospective face-to-face clinic versus telehealth clinic visit comparison study involving patients with seizures, their legal guardians, and caretakers who attend clinic. We compared travel distance, work-related factors, childcare, satisfaction of care, changes in seizure medication or diagnostics tests ordered, and willingness to cancel appointments to better understand the behavioral patterns of patients, caretakers, and providers. Our results indicate that many patients and families still prefer in-person interactions with their medical providers. Patient and family satisfaction levels were equal with both visit types. No significant difference was seen in medical management between face-to-face and telehealth visits. Also, prior seizure control did not dictate the type of visit chosen. Telehealth participants were significantly more willing to cancel appointments if asked to switch to face-to-face then face-to-face participants asked to complete telehealth visits. Surprisingly, we found that patients and families choosing telehealth were not statistically more likely to be employed or take less time off work. Also, distance from home to office was not significantly shorter for participants choosing face-to-face visits. Offering a combination of telehealth and face-to-face visits appears to be the optimal strategy in caring for patients with controlled and uncontrolled seizure disorders to ensure adherence with clinic visits and satisfaction with care. Our study suggests that providers are equally willing to adjust medications or order additional diagnostic testing regardless of visit type. Patients and families may be less likely to cancel telehealth visits than face-to-face visits; this finding may translate to improved seizure control and long-term decreased cost of care.

Utilization of epilepsy surgery in the United States: A study of the National Inpatient Sample investigating the roles of race, socioeconomic status, and insurance

Background:

Epilepsy is estimated to affect 70 million people worldwide and is medically refractory in 30% of cases.

Methods:

This is a retrospective cross-sectional study using a US database from 2012 to 2014 to identify patients aged ≥18 years admitted to the hospital with epilepsy as the primary diagnosis. The sampled population was weighted using Healthcare Cost and Utilization Project guidelines. Procedural ICD-9 codes were utilized to stratify the sampled population into two cohorts: resective surgery and implantation or stimulation procedure.

Results:

Query of the database yielded 152,925 inpatients, of which 8535 patients underwent surgical intervention. The nonprocedural group consisted of 76,000 White patients (52.6%) and 28,390 Black patients (19.7%) while the procedural group comprised 5550 White patients (64%) and 730 Black patients (8.6%) (P < 0.001). Patients with Medicare were half as likely to receive a surgical procedure (14.8% vs. 28.4%) while patients with private insurance were twice as likely to receive a procedure (53.4% vs. 29.3%), both were statistically significant (P < 0.01). Those in the lowest median household income quartile by zip code (<$40,000) were 68% less likely to receive a procedure (21.5% vs. 31.4%) while the highest income quartile was 133% more likely to receive a procedure (26.1% vs. 19.5%). Patients from rural and urban nonteaching hospitals were, by a wide margin, less likely to receive a surgical procedure.

Conclusion:

We demonstrate an area of need and significant improvement at institutions that have the resources and capability to perform epilepsy surgery. The data show that institutions may not be performing enough epilepsy surgery as a result of racial and socioeconomic bias. Admissions for epilepsy continue to increase without a similar trend for epilepsy surgery despite its documented effectiveness. Race, socioeconomic status, and insurance all represent significant barriers in access to epilepsy surgery. The barriers can be remedied by improving referral patterns and implementing cost-effective measures to improve inpatient epilepsy services in rural and nonteaching hospitals.

How much time is enough? Establishing an optimal duration of recording for ambulatory video EEG

OBJECTIVE

Ambulatory video EEG allows for extended recording of EEG in the comfort of a patient's home. However, the optimal duration of recording to capture clinical events is yet to be established. The current study uses retrospective analyses to identify an optimal recording duration for at-home video EEG.

METHODS

A retrospective review was performed utilizing an anonymized database of ambulatory video EEG recordings performed between March and September 2020 with a national in-home EEG provider. Only completed assessments with neurologists' reads of raw data were reviewed, resulting in 3644 unique studies divided into three age cohorts: pediatrics (n = 941), adult (n = 2020), and geriatric (n = 683). Cohorts were characterized by assessment yield and time to first typical clinical event, as well as subsequent typical events over duration of recording.

RESULTS

Frequency distributions reveal over half of first events are captured within 12 hours, but longer recording durations capture a much wider majority of both first typical events, as well as the mean number of subsequent events (5 clinical events). In 72 hours, over 97% of first events were observed in adult and geriatric patients, as well as over 95% of the mean number of subsequent events. In children, time to first event was significantly earlier than either adult or geriatric samples, with 98% of first events, and 92.8% of the mean number of subsequent events being observed in 48 hours.

SIGNIFICANCE

These results from a large-scale, national dataset of patients using in-home EEG monitoring suggests recording at least 48 hours in duration for children, and at least 72 hours in duration for adult and geriatric samples, is optimal to maximize the likelihood of observing typical clinical events to facilitate diagnosis.

Underutilization of epilepsy surgery: Part II: Strategies to overcome barriers

Interventions focused on utilization of epilepsy surgery can be divided into groups: those that improve patients' access to surgical evaluation and those that facilitate completion of the surgical evaluation and treatment. Educational intervention, technological innovation, and effective coordination and communication can significantly improve patients' access to surgery. Patient and public facing, individualized (analog and/or digital) communication can raise awareness and acceptance of epilepsy surgery. Educational interventions aimed at providers may mitigate knowledge gaps using practical and concise consensus statements and guidelines, while specific training can improve awareness around implicit bias. Innovative technology, such as clinical decision-making toolkits within the electronic medical record (EMR), machine learning techniques, online decision-support tools, nomograms, and scoring algorithms can facilitate timely identification of appropriate candidates for epilepsy surgery with individualized guidance regarding referral appropriateness, postoperative seizure freedom rate, and risks of complication after surgery. There are specific strategies applicable for epilepsy centers' success: building a multidisciplinary setup, maintaining/tracking volume and complexity of cases, collaborating with other centers, improving surgical outcome with reduced complications, utilizing advanced diagnostics tools, and considering minimally invasive surgical techniques. Established centers may use other strategies, such as multi-stage procedures for multifocal epilepsy, advanced functional mapping with tailored surgery for epilepsy involving the eloquent cortex, and generation of fresh hypotheses in cases of surgical failure. Finally, improved access to epilepsy surgery can be accomplished with policy changes (e.g., anti-discrimination policy, exemption in transportation cost, telehealth reimbursement policy, patient-centered epilepsy care models, pay-per-performance models, affordability and access to insurance, and increased funding for research). Every intervention should receive regular evaluation and feedback-driven modification to ensure appropriate utilization of epilepsy surgery.

Epilepsy treatment gap and stigma reduction in Pakistan: A tested public awareness model

High epilepsy treatment gap (ETG) and stigma remain a major issue globally. Addressing the basic problems is necessary, for advances in management to be effective. According to the 1987 population-based study, prevalence of active epilepsy in Pakistan is 0.98% with 98.1% ETG in rural and 72.5% in urban population and the presence of stigma. These dismal figures were a stimulus for our reported activities. Recognizing the problems faced by 2.2 million people with epilepsy (PWE) in the country, a group of volunteers mostly from the medical community has attempted to address these issues with an ongoing sustained awareness program over the last 18 years, working within the constraints of prevailing healthcare system, with gratifying results. In 2001, under a nongovernmental organization (NGO), the Comprehensive Epilepsy Control Programme of Pakistan (CECP) was launched to address the various paucities in knowledge, attitude, and practice about epilepsy; especially ETG and stigma. The CECP has two primary components: Epilepsy Support Pakistan (CECP-ESP) for awareness and mass education and National Epilepsy Centre (CECP-NEC) for holistic management of PWE, professional education, and research. Both work in tandem, and there is an overlap of their activities. This article only evaluates the outcome of sustained awareness activities of the CECP-ESP, through direct and indirect measures after 5 years of its initiation. A significant reduction in ETG and stigma exclusively through public awareness has been possible. This model can be easily replicated by any country, with involvement of the local population.

Self-management skills and behaviors, self-efficacy, and quality of life in people with epilepsy from underserved populations

PURPOSE

People with epilepsy (PWE) from underserved populations face significant barriers to epilepsy management and therefore may lack knowledge about epilepsy and self-management (SM) of epilepsy. This paper evaluates SM practices, self-efficacy, outcome expectancy, quality of life, and personal impact of epilepsy in PWE from underserved populations as compared with all PWE.

METHODS

Recruitment for the Managing Epilepsy Well (MEW) Network PAUSE to Learn Your Epilepsy study occurred from October 2015 to March 2019. Participants were assessed at baseline; after SM education intervention; and 6-, 9-, and 15-month postbaseline assessment. Baseline data from 112 PWE were analyzed for this report.

RESULTS

Study population was diverse: 63% were women, 47.3% were non-Hispanic black, 24.1% were Hispanic, and 57.4% had public healthcare coverage. Participants on average had epilepsy for 14 years, and 49.1% reported at least one seizure within the past month, but only 27% reported having used a seizure diary or calendar for seizure tracking. Self-management practices & behaviors were significantly lower among PWE from underserved populations than all PWE, though self-efficacy among PWE from underserved populations was significantly higher.

CONCLUSION

This study identifies the unique epilepsy SM needs of PWE from underserved populations. We discuss the need for a personalized approach for developing SM skills and behaviors among these PWE.