Patient safety events in hospital care of individuals with epilepsy

Prevalence and prognosis of seizures among patients undergoing mechanical thrombectomy for acute ischemic stroke: A look at pre-2015 aha/asa guidelines update regarding endovascular treatment

BACKGROUND

Mechanical Thrombectomy (MT) is standard of care for eligible patients with Acute Ischemic Stroke (AIS) due to large vessel occlusion (LVO). With increasing use of MT, clinicians are more likely to encounter seizures, a potential complication of AIS treated with MT. Tracking future trends in the burden of post-stroke seizure associated with MT will require baseline pre-approval benchmark estimates of its frequency and outcomes.

METHODS

All patients with AIS who underwent MT (International Classification of Diseases, Ninth Revision, Clinical Modification; ICD-9-CM procedure code: 39.74) were identified from the National Inpatient Sample (NIS) 2006-2014, using appropriate ICD-9-CM codes. We identified a subset of patients with seizures using ICD-9-CM secondary discharge diagnoses codes 780.3x and 345.x. We computed the rate of seizures overall and across pre-specified demographic, clinical, and healthcare system-related variables. Finally, we assessed the independent association of mortality with seizures using a multivariable logistic regression model.

RESULTS

Of 30137 (weighted) patients with AIS who underwent MT, 1,363 (4.5%) had seizures. Patients who had seizures were younger, privately insured, or Medicaid beneficiaries, and frequently died in the hospital. There were no statistically significant differences between the seizures and no-seizures groups by race, sex, IV thrombolysis with recombinant tissue plasminogen activator, length of stay, and the number of medical comorbidities. However, patients who underwent MT and developed seizures had 75% higher odds of in-hospital mortality (adjusted OR 95% CI 1.75; 1.22-2.49).

CONCLUSION

In this nationwide sample, prior to the 2015 AHA/ASA guidelines update supporting MT use, seizures occurred in one of twenty patients with AIS treated with MT, and occurrence of seizure was independently associated with a nearly two-fold increase in the odds of in-hospitality death.

Predictors of long length of hospital stay among elders admitted with seizures in a tertiary centre: a prospective study

OBJECTIVE

Population ageing is a global phenomenon, and life expectancy in Brazil is growing fast. Epilepsy is the third most important chronic neurological disorder, and its incidence is higher among elderly patients than in any other segment of the population. The prevalence of epilepsy is greater among inpatients than in the general population and it is related to long length of hospital stay (LOS), which is associated with hospital mortality and higher healthcare costs. Despite these facts, reports of elderly inpatients admitted with seizures and associated outcomes are scarce. To identify predictors of long LOS among elderly inpatients admitted with seizures.

METHODS

We prospectively enrolled elders admitted with epileptic seizures or who experienced seizures throughout hospitalization between November 2015 and August 2019. We analysed demographic data, neurological disorders, clinical comorbidities, and seizure features to identify risk factors.

RESULTS

The median LOS was 11 days, with an interquartile range (IQR) of 5-21 days. The frequency of long LOS (defined as a period of hospitalization ≥12 days) was 47%. Multivariate analysis showed there was an exponential increase in long LOS if a patient showed any of the following conditions: intensive care unit (ICU) admission (OR=4.562), urinary tract infection (OR=3.402), movement disorder (OR=5.656), early seizure recurrence (OR=2.090), and sepsis (OR=4.014).

CONCLUSION

Long LOS was common among elderly patients admitted with seizures, and most predictors of long LOS found in this cohort might be avoidable; these findings should be confirmed with further research.

Enzyme-inducing antiseizure medication utilization in patients with epilepsy and vascular risk factors

OBJECTIVES

Several lines of evidence have suggested that exposure to enzyme-inducing antiseizure medications (EIASMs) may result in the subsequent development of hyperlipidemia, a well-known risk factor for vascular disease. This may be an issue of concern particularly in the context of additional comorbid vascular risk factors. We therefore aimed to investigate trends of and associations with the use of these medications among adult patients with epilepsy.

METHODS

The cross-sectional Medical Expenditure Panel Survey (MEPS) was interrogated to ascertain the prevalence of use of EIASMs by noninstitutionalized adult patients with epilepsy in the United States between the years 2004 and 2015. Any patient prescribed carbamazepine, phenytoin, phenobarbital, or primidone within a given year was defined as having been prescribed an EIASM. Trends over three-year epochs were evaluated with univariate logistic regression, while associations with demographic factors, vascular risk factors, and vascular disease were evaluated using a chi-square test corrected for survey design as well as multivariate logistic regression.

RESULTS

A total of 2281 (unweighted) patients were identified, representing 1,781,237 individuals. Between 2004 and 2015, 45.9% (95% confidence interval [CI]: 42.4%-49.4%) were prescribed EIASMs. Approximately one-quarter of patients aged 65 years and above used EIASMs compared with 18.5% of younger patients (odds ratio [OR]: 1.83, 95% CI = 1.27-2.65). Female patients (OR = 0.61, 95% CI = 0.47-0.79) and those with heart disease (OR: 0.63, 95% CI = 0.45-0.89) were significantly less likely to be prescribed EIASMs. Among those prescribed EIASMs, 38.9% had hypertension, 12.2% had diabetes, 61.6% were overweight or obese, 17.3% heart disease, 17.2% had a history of a cerebrovascular event, and 28.5% had diagnosed hyperlipidemia. Nonetheless, between 2004-2006 and 2013-2015, the odds of EIASM prescription decreased significantly (OR: 0.39, 95% CI: 0.28-0.55).

CONCLUSIONS

A substantial proportion of patients with comorbid vascular disease or vascular risk factors (e.g., hypertension and older age) is prescribed EIASMs. This could potentially increase patients' risk for subsequent negative outcomes such as cardiovascular or cerebrovascular disease. Though utilization of these medications has decreased, further efforts toward increasing use of newer antiseizure medications (ASMs) that are not associated with similar risks may be warranted.

Trends in documented cannabis use disorder among hospitalized adult epilepsy patients in the United States

OBJECTIVE

Patients with epilepsy are at increased risk for mental health and substance abuse disorders. Given ongoing contemporary societal controversies about medicinal and recreational cannabis use, we aimed to ascertain recent nationwide prevalence, trends, and psychiatric diagnoses associated with cannabis use disorders (CUD) among epilepsy patients.

METHODS

We interrogated the National Inpatient Sample database comprising a total of 398,936 adults (aged 18 years and above) with epilepsy between the years 2006 and 2014, identified using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes 780.39 and 345.X. A subset of these patients with a secondary discharge diagnosis of CUD (ICD-9-CM: 304.30, 304.31, 304.32, 305.20, 305.21, and 305.22), excluding those in remission, were selected. Logistic regression model adjusting for gender, race, age, primary payer, bed size, household income, region, teaching hospital, admission day, length of stay (LOS), Charleson Comorbidity Index (CCI) and, year category was used to ascertain the independent associations of demographic features and mental health comorbidities with CUD. Finally, we generated CUD trend estimates overall and by psychiatric diagnoses.

RESULTS

Of all hospitalized patients with epilepsy, 3.19 % had CUD. After adjusting for confounders, CUD was higher in males, Blacks, those aged 18-44 years, those with lower incomes, and those hospitalized during more recent years. CUD was more likely to be present in epilepsy patients with depression, bipolar disorder, and tobacco use disorder (TUD). In contrast, alcohol use disorder (AUD) was associated with lower odds of CUD. Overall, CUD prevalence more than doubled among epilepsy patients (2.18 % in 2006 to 4.41 % in 2014). Among patients with PTSD, CUD prevalence increased over fivefold, and it nearly tripled in those with tobacco use disorder.

SIGNIFICANCE

Documented CUD has doubled among hospitalized patients with epilepsy in the United States over the last decade and is especially more prevalent in specific demographic and mental health disorder groups. Increased awareness and potential screening for CUD in high-risk epilepsy patients may be warranted, given the risk for potential complications.

Trends in prevalence and treatment of depressive symptoms in adult patients with epilepsy in the United States

OBJECTIVE

Depressive symptoms are a common comorbidity among adults with epilepsy (AWE). Prior estimates regarding prevalence and treatment of depressive symptoms in AWE have been largely based on samples of tertiary care cohorts that may not be generalizable. We aimed to provide a representative population estimate of the prevalence and treatment of depressive symptoms over time in AWE in the United States as measured by a validated depression screen.

METHOD

Data from the Medical Expenditure Panel Survey (MEPS) were analyzed from 2004 to 2015 to determine the prevalence of "screen positive" depressive symptoms (SPDS) among AWE as evaluated by the Patient Health Questionnaire-2 (PHQ-2). We defined pharmacotherapy for depressive symptoms as the prescription of any antidepressant, antipsychotic, anxiolytic, or central nervous system stimulant for the "Clinical Classification Code" of mood disorders within the year sampled, and psychotherapy as any outpatient or office-based visit for "mood disorders" for that year sampled. We analyzed temporal trends and explanatory variables for treatment using the Cochran-Armitage test and logistic regression, respectively.

RESULTS

Our sample included 2024 AWE, representing 1,736,023 patients nationwide. This included 517 AWE with SPDS (AWE-SPDS), representing 401,452 AWE, and 1507 AWE who screened negative for depressive symptoms (AWE-SNDS), representing 1,334,571 AWE. The prevalence of SPDS was 23.1% (95% confidence interval [CI]: 20.6%-25.8%). Women (odds ratio [OR]: 1.40, 95% CI: 1.05-1.87), patients ages 35-49 (OR: 1.83, 95% CI: 1.23-2.72; compared with patients ages 18-34), and patients with Charlson Comorbidity Index ≥1 (OR: 1.92, 95% CI: 1.41-2.61) had higher odds of SPDS. There was no significant change in depressive symptoms' prevalence or treatment in AWE between the epochs of 2004-2006 and 2013-2015.

CONCLUSIONS

Despite a quarter of AWE in the United States with SPDS, fewer than half received treatment. This indicates a need for improved efforts to screen AWE for depression and treat appropriately.

Mortality and trends in stroke patients with seizures: A contemporary nationwide analysis

OBJECTIVE

Seizures are frequent among stroke patients. The goal of this study was to provide updated trends in seizures prevalence and mortality among hospitalized stroke patients.

METHODS

Data from the National Inpatient Sample was used to estimate trends in seizures prevalence among stroke patients as well as mortality by seizures status, between 2006 and 2014. We used a logistic regression model to examine the association between seizures and mortality, accounting for extraneous factors.

RESULTS

Overall 372,957 patients (6%) stroke patients had a secondary diagnosis of seizures. We found 29% higher odds of in-hospital death among stroke patients with a secondary diagnosis of seizures. The prevalence of seizures was more than two times higher among patients with hemorrhagic stroke (11.4%) compared to those with ischemic strokes (4.8%). The prevalence of seizures among stroke patients was 6.6% and 6.2% for all strokes, 12.6% and 12% for hemorrhagic strokes, and 5.3% and 5% for ischemic strokes respectively in 2006 and 2014. Although there was a steady decline in both groups, mortality rate among hospitalized stroke patients with seizures was consistently higher than in those without seizures for all strokes, ischemic strokes, and hemorrhagic strokes. Compared to patients with ischemic stroke and seizures, mortality rate was higher among patients with hemorrhagic stroke and seizures.

SIGNIFICANCE

Seizures were present in nearly one out of 15 patients hospitalized for stroke and were more frequent among those with hemorrhagic stroke. There was a decline in mortality among stroke patients during the study period, which remained significantly higher in patients with seizures than in patients without seizures, and in those with hemorrhagic stroke compared to those with ischemic stroke.

Hospital safety among neurologic patients

Objective:

To examine the frequency and type of adverse events (AEs) experienced by neurologic patients in hospital.

Methods:

This population-based, retrospective cohort study used hospital discharge abstract data for children and adults admitted to hospital from 2009 to 2015 with 1 of 9 neurologic conditions (Alzheimer disease and related dementia, brain tumor, epilepsy, motor neuron disease, multiple sclerosis, parkinsonism/Parkinson disease, spinal cord injury, traumatic brain injury, and stroke). Neurologic conditions were identified with ICD-10-CA codes. Eighteen AEs were examined with ICD-10-CA codes. The proportion of AEs was calculated, and regression analysis was used to examine factors and outcomes associated with AEs (age, sex, comorbidity, length of stay, and mortality).

Results:

The overall proportion of admissions associated with an AE among those with a neurologic condition was 11 per 100 admissions. Those with a spinal cord injury had the highest proportion of AEs (39.4 per 100 admissions). The most common AEs were infections and respiratory complications (32.0% and 16.7%, respectively). Age and the presence of comorbidities were associated with higher odds of an AE, while readmission was associated with lower odds of an AE. Having an AE was associated with increased length of stay and higher odds of mortality.

Conclusions:

This study demonstrates that neurologic patients have a high proportion of AEs in hospital. The findings provide information on the quality and safety of care for people with neurologic conditions in hospital, which can help inform future quality improvement initiatives.