Direct Cost of Medical Management of Epilepsy among Adults in Italy: A Prospective Cost-of-Illness Study (EPICOS)

Epilepsy-Related Direct Medical and Direct Non-Medical Cost in Adult Patients Living with Epilepsy at a Tertiary Neurology Center in Rwanda

Objective

Up to one in four patients living with epilepsy (PwE) mentions financial constraints as a reason for loss to follow-up at the Ndera tertiary neuropsychiatry hospital. Therefore, we evaluated the annual direct medical cost (DMC) and direct non-medical cost (DnMC) of epilepsy and calculated costs assuming different follow-up frequency.

Materials and Methods

DMC data were obtained from a descriptive retrospective study of medical records, pharmacy dispensation and hospital logs of PwE, following their initial consultation in 2018 and who adhered to the normal clinical practice of monthly consultations for one year. DnMC data were collected through structured interviews of PwE in a cross-sectional cohort in August 2020. DnMC included biomedical care costs (eg, transportation, hospitality) and non-biomedical costs (traditional healer visits). We report weighted means for total costs, health insurance costs, and out-of-pocket costs (OoP).

Results

Mean annual total cost was 389.4 US$, of which 226.2 US$ was covered by the Rwandan Health Insurance co-payment for DMC and 163.2 US$ was OoP paid by patients. Mean weighted annual DMC (n = 55) was 248.9 US$. Mean weighted annual DMC for medical consultations and antiseizure medication accounted for 30.7 US$ and 161.7 US$, respectively. Based on structured interviews (n = 69), mean weighted annual DnMC for biomedical care was 73.0 US$. Mean DnMC for traditional healer care was 67.6 US$. Weighted annual total OoP was 163.2 US$ or 20% of the GDP per capita. OoP consisted of 14% DMC co-payment, 45% biomedical DnMC, and 41% traditional healer DnMC.

Conclusion

Epilepsy-related costs at a tertiary center are an important economic burden for PwE and Rwandan Health Insurance. Biomedical and traditional healer DnMC constitute 86% of total OoP. Future prospective studies should evaluate outcomes and costs of reduced visit frequency, indirect costs, and costs of comorbidities.

Scoping review of rational polytherapy in patients with drug-resistant epilepsy

There is a paucity of literature regarding the optimal selection of combination antiseizure medications (ASMs) for drug-resistant epilepsy (DRE). The aim of this scoping review is to evaluate current evidence related to "rational polytherapy" among adults with DRE. Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Scoping Reviews (PRISMA-SCr) guidelines, PubMed, ProQuest, CINAHL, and Cochrane databases were searched using DRE- and polytherapy-related keywords. The exclusion criteria applied included: non-English; non-human studies; non-research studies; participants less than 18 years; status epilepticus; ASM monotherapy; and certain ASMs. In Covidence, two researchers independently reviewed articles for inclusion at each phase, with a third resolving conflicts. Data were extracted, with quality appraisal using the Mixed Methods Appraisal Tool (MMAT). Of the 6477 studies imported for screening, 33 studies were included. Clinical, humanistic, and economic outcomes were reported by 26, 12, and one study, respectively. Common efficacy-related clinical outcomes included ≥50% reduction in seizure frequency (n = 14), seizure freedom (n = 14), and percent reduction in seizure frequency (n = 8). Common humanistic outcomes included quality of life (n = 4), medication adherence (n = 2), sleep-related outcomes (n = 2), and physician and patient global assessments (n = 2). The economic study reported quality-adjusted life years. The median MMAT score was 80 (range: 60-100). Two studies referenced the standard definition of DRE, whereas five studies did not specifically define DRE. Gaps in the literature include limited generalizability, minimal reports in pregnancy, and lack of optimal ASM combinations, among others. Strengths of the evidence include addressing a variety of outcomes. Inconsistent definitions of DRE, small sample sizes, and heterogeneity among studies limit the ability to draw meaningful conclusions. Optimal combinations of ASMs for rational polytherapy for DRE is unclear.

Burden of illness in people with medically refractory epilepsy who suffer from daily to weekly seizures: 12-month follow-up of participants in the EPISODE study

BACKGROUND

A small group of people with epilepsy suffers from frequent seizures despite the available pharmacological and non-pharmacological interventions. The impact of epilepsy on these people extends beyond health-related quality of life (HRQoL), impacting a person's broader well-being and ability to participate in society. This study describes the burden of medically refractory epilepsy in people who suffer from daily to weekly seizures, in terms of HRQoL, well-being, and societal costs.

METHODS

Data from the EPISODE study on (cost-) effectiveness of seizure dogs for adults with severe medically refractory epilepsy were used, collected in 25 patients during the first 12 months before they were partnered with a certified seizure dog. Data comprised seizure diaries covering 365 days and five three-monthly surveys, including the EQ-5D-5L, QOLIE-31-P, and ICECAP-A to measure HRQoL and well-being. A societal perspective was applied to estimate costs using the iMCQ and iPCQ questionnaires about healthcare use, informal care, and productivity losses.

RESULTS

Daily seizure frequency and survey data were collected in 25 patients. A minimum of 114 observations was available for each instrument included in the survey. A total of 80% of participants experienced seizures on three or more days per week, with a median ranging from 1 to 17 seizures per seizure day. The mean EQ-5D-5L utility score was 0.682 (SD 0.235), which is considerably lower than the age-adjusted general population average. The mean QOLIE-31-P and ICECAP-A scores were 55.8 (SD 14.0) and 0.746 (SD 0.172), respectively. The average annual total cost amounted to €39,956 (range €3,804-€132,64). Informal care accounted for the largest share of costs (50%); those who received informal care reported, on average, 26 h per week (SD 30).

CONCLUSIONS

Severe medically refractory epilepsy is associated with a considerable burden of illness at the patient and societal level. People with this condition have significantly reduced HRQoL and well-being and are limited in their ability to work while having substantial medical costs and a strong dependency on informal care.

Self-perceived burden and associated factors in Chinese adult epilepsy patients: A cross-sectional study

Objectives

Epilepsy requires long-term or lifelong treatment, and patients are prone to financial, emotional and psychological burdens that can cause psychological changes during the treatment process. This study aimed to describe the prevalence and associated factors of Self-Perceived Burden (SPB) in Chinese adult epilepsy patients, informing the treatment and nursing of epilepsy.

Methods

A total of 143 adult epilepsy patients were included in this study, and the clinical questionnaire survey was conducted at the Third Xiangya Hospital of Central South University in Hunan, China, from March 2022 to June 2022. The sociodemographic and clinical characteristics of adult epilepsy patients were collected using a self-developed questionnaire, and the data on SPB, stigma and quality of life were collected through the Self-Perceived Burden Scale (SPBS), Kilifi Stigma Scale for Epilepsy (KSSE) and Quality of Life in Epilepsy Inventory-31 (QOLIE-31). Multiple linear regression analysis was used to determine the associated factors influencing SPB in adult epilepsy patients.

Results

The average score of SPBS for the 143 adult epilepsy patients was 30.77 (SD = 9.06), and 89.5% of them had obvious SPB. The results of the univariate analysis showed that residence, monthly household income, duration of epilepsy, type of medication and electroencephalogram finding were associated with SPB (P < 0.05). In Spearman correlation analysis indicated that SPBS score were positively correlated with KSSE score (r = 0.510, P < 0.05) while negatively correlated with QOLIE-31 score (r = −0.506, P < 0.05). Multiple linear regression analysis revealed that factors such as KSSE, type of medication, residence and electroencephalogram finding accounted for 32.8% of the factors influencing SPB in adult epilepsy patients.

Conclusion

89.5% of adult epilepsy patients have varying degrees of SPB, which is associated with high stigma and poor quality of life. Therefore, during the treatment and nursing of adult epilepsy patients, clinical staff should pay attention to the psychological status of patients, help them reduce their psychological burden, and guide them to develop a healthy lifestyle.

Analysis of Patients with Focal Epilepsy and Drug-Resistant Epilepsy in Italy: Evaluation of Their Characteristics, Therapeutic Pathway and the Consumption of Healthcare Resources

Purpose

A retrospective analysis was conducted to estimate the number of patients with focal epilepsy and drug-resistant epilepsy (DRE) and their characteristics, the therapeutic patterns, the consumption of health resources in a real-world Italian setting.

Patients and Methods

A retrospective study was carried out on the administrative databases of a sample of Italian Health Departments, covering approximately 8.7 million health-assisted individuals. All adult patients with at least one hospitalization for focal epilepsy and an electroencephalogram (between 01/2010 and 12/2019), and at least one prescription of antiseizure medication (ASM) (between 01/2011 and 12/2018) were included in the study. Patients with at least two treatment failures and treated with a subsequent ASM were considered DRE.

Results

Overall, 1897 patients with focal epilepsy (mean age 56 years, 47% male) were identified, of which 485 (25.6%) with DRE (mean age 53 years, 43% male). Among patients with focal epilepsy and DRE, respectively, 48% and 54% had essential hypertension, 23.4% and 26.6% had cardiovascular disease, and 46.3% and 62.1% had peptic ulcer/prescription of gastric secretion inhibitors. During follow-up, patients with focal epilepsy maintained first-line treatment for 53.9 months; among these, 52% passed to the second-line, and 485 (25.6% of the total) began third-line treatment. In patients with focal epilepsy, the mean cost was € 4448 (of which € 1410 were epilepsy-related), and in DRE patients total expenditures averages € 5825 (of which € 2165 were epilepsy-related). In both patients with focal epilepsy and DRE, hospitalizations represented the most impacting item of expenditure.

Conclusion

The present analysis conducted in a setting of Italian clinical practice has shown that 25% of patients with focal epilepsy were resistant to antiepileptic treatments. Furthermore, these results showed that health-care costs for the management of epileptic patients were mainly accountable for the costs related to the disease-management and to hospitalizations.

The global cost of epilepsy: A systematic review and extrapolation

OBJECTIVE

Global action for epilepsy requires information on the cost of epilepsy, which is currently unknown for most countries and regions of the world. To address this knowledge gap, the International League Against Epilepsy Commission on Epidemiology formed the Global Cost of Epilepsy Task Force.

METHODS

We completed a systematic search of the epilepsy cost-of-illness literature and identified studies that provided a comprehensive set of direct health care and/or indirect costs, followed standard methods of case identification and cost estimation, and used data on a representative population or subpopulation of people with epilepsy. Country-specific costs per person with epilepsy were extracted and adjusted to generate an average cost per person in 2019 US dollars. For countries with no cost data, estimates were imputed based on average costs per person of similar income countries with data. Per person costs for each country were then applied to data on the prevalence of epilepsy from the Global Burden of Disease collaboration adjusted for the treatment gap.

RESULTS

One hundred one cost-of-illness studies were included in the direct health care cost database, 74 from North America or Western Europe. Thirteen studies were used in the indirect cost database, eight from North America or Western Europe. The average annual cost per person with epilepsy in 2019 ranged from $204 in low-income countries to $11 432 in high-income countries based on this highly skewed database. The total cost of epilepsy, applying per person costs to the estimated 52.51 million people in the world with epilepsy and adjusting for the treatment gap, was $119.27 billion.

SIGNIFICANCE

Based on a summary and extrapolations of this limited database, the global cost of epilepsy is substantial and highly concentrated in countries with well-developed health care systems, higher wages and income, limited treatment gaps, and a relatively small percentage of the epilepsy population.

Multicenter, cross-sectional study of the costs of illness and cost-driving factors in adult patients with epilepsy

OBJECTIVE

This study was undertaken to quantify epilepsy-related costs of illness (COI) in Germany and identify cost-driving factors.

METHODS

COI were calculated among adults with epilepsy of different etiologies and severities. Multiple regression analysis was applied to determine any epilepsy-related and sociodemographic factors that serve as cost-driving factors.

RESULTS

In total, 486 patients were included, with a mean age of 40.5 ± 15.5 years (range = 18-83 years, 58.2% women). Mean 3-month COI were estimated at €4911, €2782, and €2598 for focal, genetic generalized, and unclassified epilepsy, respectively. The mean COI for patients with drug-refractory epilepsy (DRE; €7850) were higher than those for patients with non-DRE (€4720), patients with occasional seizures (€3596), or patients with seizures in remission for >1 year (€2409). Identified cost-driving factors for total COI included relevant disability (unstandardized regression coefficient b = €2218), poorer education (b = €2114), living alone (b = €2612), DRE (b = €1831), and frequent seizures (b = €2385). Younger age groups of 18-24 years (b = -€2945) and 25-34 years (b = -€1418) were found to have lower overall expenditures. A relevant disability (b = €441), DRE (b = €1253), frequent seizures (b = €735), and the need for specialized daycare (b = €749) were associated with higher direct COI, and poorer education (b = €1969), living alone (b = €2612), the presence of a relevant disability (b = €1809), DRE (b = €1831), and frequent seizures (b = €2385) were associated with higher indirect COI.

SIGNIFICANCE

This analysis provides up-to-date COI data for use in further health economics analyses, highlighting the high economic impacts associated with disease severity, disability, and disease-related loss of productivity among adult patients with epilepsy. The identified cost drivers could be used as therapeutic and socioeconomic targets for future cost-containment strategies.

The economic burden of newly diagnosed epilepsy in Spain

OBJECTIVE

The aim of this study was to determine the hospital burden and economic impact of epilepsy in adults in Spain and identify characteristics associated with higher direct medical costs.

METHOD

Patients newly diagnosed with epilepsy at the outpatient epilepsy unit of a tertiary hospital in Spain in 2012 were included. Sociodemographic and clinical data and use of health resources were collected retrospectively from electronic medical records from the time of diagnosis to the end of follow-up (2019). Direct costs (in 2012 Euro) were estimated and linear regression models built to explore predictors of higher costs.

RESULTS

We studied 110 patients with newly diagnosed epilepsy. Their mean (SD) age was 52.6 (19.6) years and 53.6% were men. Eighty-nine patients (80.9%) had focal epilepsy and 45 (40.9%) had an unknown etiology. At 6 months, 79.1% of patients were classified as responders and 17.6% as having drug-resistant epilepsy. The mean direct cost in the first year of epilepsy diagnosis was €3816.06, 49.7% of which was due to hospital admissions. The mean annual cost per patient was €2584.17, 51.4% of which was due to anti-seizure medications (ASMs). Focal epilepsy and poor response in the first 6 months of treatment predicted higher annual costs, while focal epilepsy and pre-existing comorbidities predicted higher costs in the first year.

CONCLUSIONS

The direct cost of newly diagnosed epilepsy in adults in our area is €2584 per patient/year. Anti-seizure medication use is the main cost driver. Focal epilepsy, comorbidities, and poor response to ASMs are independent predictors of higher costs.

Evaluation of the direct costs of epilepsy in a sample of Egyptian patients following up in Ain Shams University Hospital

Background

Epilepsy is a chronic disorder of the brain, and it is considered as the 4th common neurological disorder. Epilepsy is associated with an economic burden by imposing a significant burden on both the individuals who have the condition and on those around them, as well as for the society.

Objective

Our objective is to study and evaluate the direct costs associated with the medical management of epilepsy, one of the most common neurological conditions.

Methods

Observational, cross-sectional 4-month study started in December 2018 till April 2019 in patients between 2 and 60 years of age with epilepsy without other concomitant diseases. The direct medical costs include the number of neurology and emergency room visits, number and type of diagnostic tests, days of hospitalization, and treatment administered for epilepsy.

Results

We studied data from 194 patients, with a mean age of 30.6 years; the mean cost for treatment with carbamazepine was 78.6 Egyptian pound (EGP); for valproate, the cost was 288.4 EGP, and for levetiracetam, the cost was 491 EGP. The mean cost of electroencephalogram (EEG) is 108 EGP, and for computer tomography scan (CT) of the brain and magnetic resonance imaging (MRI) of the brain, it is 149.4 and 423.7 EGP respectively. The mean cost for hospitalization was 610.5 EGP, and the cost for intensive care unit (ICU) stay was 515.4 EGP.

Conclusion

The economic cost of epilepsy constitutes a major burden for the patients as well as their families; most of the direct cost was attributed to the purchase of AEDs. This necessitates creating strategies to ensure regular access to affordable AEDs as well as introducing other varieties of AEDs more potent with less side effects.

Use of Emergency Medication in Adult Patients with Epilepsy: A Multicentre Cohort Study from Germany

BACKGROUND

Emergency treatment with benzodiazepines is indicated in prolonged seizures, seizure clusters and status epilepticus.

OBJECTIVE

The aim of this study was to evaluate the use of emergency medication in adult patients with epilepsy.

PATIENTS AND METHODS

All adult epilepsy patients attending the epilepsy outpatient clinics of the university hospitals in Frankfurt and Marburg in 2015 were asked to participate in this questionnaire-based, retrospective survey.

RESULTS

A total of 481 patients with a mean age of 43.4 years (range 18-94 years, 54% female) participated in the study. Among them, 134 patients (27.9%) reported on the prescription of an emergency medication during the last year. Patients receiving emergency medication were younger and exhibited a lower age at epilepsy onset, a higher seizure frequency and a higher number of regularly taken antiepileptic drugs. The most frequently taken emergency drugs were oral lorazepam tablets (65.7%; n = 88 out of 134), followed by buccal midazolam (23.9%, n = 32) and rectal diazepam (17.9%, n = 24). The most common indications for administering the emergency medication were seizures continuing for several minutes (35.1%, n = 47), but almost the same number of patients (33.6%, n = 45) stated that the rescue medication was given during or after every seizure. Regarding adverse events, sedation was named as a major (18.7%, n = 25) or moderate (29.1%; n = 39) problem by a substantial number of patients. Difficulties in administration were reported by 17 (13%) patients. Two-thirds assessed the efficacy of their emergency medication as good (50.7%, n = 68) or as very good (15.7%, n = 21). For multivariate logistic regression analysis, aspects such as young age at onset, active epilepsy, structural etiology, presence of generalised tonic-clonic seizures, past medical history of status epilepticus and living with another person independently predicted prescription of emergency medication.

CONCLUSIONS

In most cases, unsuitable benzodiazepines with slow absorption due to oral administration were prescribed, or buccal midazolam solution was used off-label in adults. Furthermore, inappropriate use of emergency medication at every seizure was reported by a substantial number of participating patients.

Evaluation of long-term antiepileptic drug use in patients with temporal lobe epilepsy: Assessment of risk factors for drug resistance and polypharmacy

PURPOSE

To evaluate risk factors for drug resistance and polypharmacy in patients with temporal lobe epilepsy.

METHODS

Patients with temporal lobe epilepsy, treated for more than 5 years, completed questionnaires on antiepileptic drug use and effect. Logistic regression models were used for analysis of risk factors.

RESULTS

Of 135 patients included in the study, 65% were classified as drug resistant and 41% identified as using polypharmacy. Poor effects associated with first-choice antiepileptic drug were reported by 59% of the patients, and 70% reported poor effects of second-line treatment. The most frequently used first-generation antiepileptic drugs had a similar mean effect to those of second-generation. Univariate regression analyses showed a significant association between drug resistance and mesial temporal sclerosis, seizure onset below 18 years, and lack of family history of epilepsy. However, multivariate regression analysis showed no association with any demographic or clinical features. Unsuccessful treatment with the first antiepileptic drug increased the risk of drug resistance by 18 times, and the risk of poor effect from the second antiepileptic drug by 9 times. Disease duration was associated with annual risk for drug resistance of 7% and for polypharmacy of 5%.

CONCLUSIONS

A poor effect from initial pharmacotherapy is the only early risk factor for drug resistance found in this study. Long disease duration increases the risk of drug resistance and polypharmacy. Second-generation antiepileptic drugs provide no additional effect for poor responders to first-generation drugs.

Trends in resource utilization and prescription of anticonvulsants for patients with active epilepsy in Germany from 2003 to 2013 - A ten-year overview

This study evaluated trends in resource use and prescription patterns in patients with active epilepsy over a 10-year period at the same outpatient clinic of a German epilepsy center. We analyzed a cross-sectional patient sample of consecutive adults with active epilepsy over a 3-month period in 2013 and compared them with equally acquired data from the years 2003 and 2008. Using validated patient questionnaires, data on socioeconomic status, course of epilepsy, as well as direct and indirect costs were recorded. A total of 198 patients (mean age: 39.6±15.0years, 49.5% male) were enrolled and compared with our previous assessments in 2003 (n=101) and 2008 (n=151). In the 2013 cohort, 75.8% of the patients had focal epilepsy, and the majority were taking antiepileptic drugs (AEDs) (39.9% monotherapy, 59.1% polytherapy). We calculated epilepsy-specific costs of €3674 per three months per patient. Direct medical costs were mainly due to anticonvulsants (20.9% of total direct costs) and to hospitalization (20.8% of total direct costs). The proportion of enzyme-inducing anticonvulsants and 'old' AEDs decreased between 2003 and 2013. Indirect costs of €1795 in 2013 were mainly due to early retirement (55.0% of total indirect costs), unemployment (26.5%), and days off due to seizures (18.2%). In contrast to our previous findings from 2003 and 2008, our data show a stagnating cost increase with slightly reduced total costs and balanced direct and indirect costs in patients with active epilepsy. These findings are accompanied by an ongoing cost-neutral increase in the prescription of 'newer' and non-enzyme-inducing AEDs. However, the number and distribution of indirect cost components remained unchanged.

Observational multicentre study into the use of antiepileptic drugs in Spanish neurology consultations

INTRODUCTION

The study aims to quantify the types of antiepileptic drugs (AED) prescribed in neurology consultations.

MATERIAL AND METHOD

This descriptive, observational study included a sample of 559 patients older than 14 years, diagnosed with epilepsy, and receiving pharmacological treatment. Data were collected at outpatient consultations by 47 Spanish neurologists in May 2016. Epilepsy was defined based on the International League Against Epilepsy classification. According to the year of marketing, AEDs were categorised as classic (before 1990) or new (after 1990). We performed a descriptive analysis of qualitative and quantitative variables.

RESULTS

Female patients accounted for 54.6% of the sample. Mean age was 42.7 years; mean age of onset was 22.4. Regarding epilepsy type, 75.7% of patients experienced partial seizures, 51.5% were symptomatic,32.4% had refractory epilepsy, 35.6% had been seizure-free for the previous year, and 59.2% had associated comorbidities.A total of 1103 AED prescriptions were made; 64.6% of prescriptions were for new AEDs; 85.4% of patients received new AEDs. Patients received a mean of 2 AEDs (range, 1-5). A total of 59.6% of patients received polytherapy.The most frequently prescribed AEDs were levetiracetam (42.6%), valproic acid (25.4%), lamotrigine (19.5%), carbamazepine (17.9%), and lacosamide (17.5%). No AED was employed exclusively as monotherapy. The most frequently prescribed AEDs for generalised and partial seizures were valproic acid (48.2%) and levetiracetam (43.2%), respectively. Valproic acid was less frequently prescribed to female patients. Patients with refractory epilepsy or with associated comorbidities were more frequently prescribed a combination of new and classic AEDs (48.7% and 45.6%, respectively) than only one type of AED.

CONCLUSIONS

The majority of patients received new AEDs. The combination of classic and new AEDs was more frequently prescribed to patients with refractory epilepsy or with associated comorbidities.

Value of clinical features to differentiate refractory epilepsy from mimics: a prospective longitudinal cohort study

BACKGROUND AND PURPOSE

Misdiagnosis of refractory epilepsy (rE) is common and such patients experience a long diagnostic delay. Our aim was to identify key clinical/laboratory factors in order to obtain an alternative diagnosis in patients referred for rE.

METHODS

Between January 2010 and December 2015, 125 consecutive patients with a diagnosis of rE were prospectively enrolled. All patients underwent a comprehensive neurological, neuropsychiatric and cardiological evaluation, and had an observation time of at least 1 year after the study entry.

RESULTS

Diagnosis of rE was confirmed in 104/125 (83.2%) patients (55 women, mean age 38.8 ± 14.3 years). Thirteen/125 patients (10.4%, seven women, mean age 50.8 ± 20.9) were diagnosed with syncope, which was cardiac/cardio inhibitory in 9/13 (69%). The remaining 8/125 patients (6.4%, six women, mean age 41.2 ± 14.6 years) were diagnosed with psychogenic non-epileptic seizures. Age at onset had a high accuracy in differentiating patients with syncope from others, with the best cut-off age at 35 years and above. Abnormal brain magnetic resonance imaging (MRI) had a significant yield of about 70% in rE. A diagnostic model including age at onset and brain MRI was highly accurate in differentiating patients with syncope from others. In patients with cardiac/cardio inhibitory syncope, the point score of historical features was ≥1 and falsely favoured the diagnosis of epileptic seizures.

CONCLUSIONS

This prospective cohort study identifies rE mimics who are at high risk of morbidity and mortality. rE starting in adulthood should raise a high suspicion of cardiac syncope. Brain MRI is accurate in differentiating rE from other conditions.

The Burden of Severely Drug-Refractory Epilepsy: A Comparative Longitudinal Evaluation of Mortality, Morbidity, Resource Use, and Cost Using German Health Insurance Data

Purpose

To evaluate long-term outcome of three years and treatment patterns of patients suffering from severely drug-refractory epilepsy (SDRE).

Methods

This analysis was population-based and retrospective, with data collected from four million individuals insured by statutory German health insurance. ICD-10 codes for epilepsy (G40*) and intake of anticonvulsants were used to identify prevalent cases, which were then compared with a matched cohort drawn from the population at large. Insurance data were available from 2008 to 2013. Any patient who had been prescribed with at least four different antiepileptic drugs (AEDs) in an 18-month period was defined as an SDRE case.

Results

A total of 769 patients with SDRE were identified. Of these, 19% were children and adolescents; the overall mean age was 42.3 years, 45.4% were female and 54.6% male. An average of 2.7 AEDs per patient was prescribed during the first follow-up year. The AEDs most commonly prescribed were: levetiracetam (53.5%), lamotrigine (41.4%), valproate (41.3%), lacosamide (20.4%), and topiramate (17.8%). During 3-year follow-up, there was an annual rate of hospitalization in the range 42.7 to 55%, which was significantly higher than the 11.6–12.8% (p < 0.001) for the matched controls. Admissions to hospital because of epilepsy ranged between 1.7 and 1.9 per year, with an average duration for each epilepsy-caused hospitalization of 10–11.1 days. The number of comorbidities for SDRE patients was significantly increased compared with the matched controls: depression (28% against 10%), vascular disorders (22% against 5%), and injury rates were also higher (head 16% against 3%, trunk and limbs 16% against 8%). The 3-year mortality rate for SDRE patients was 14% against 2.1% in the matched cohort.

Conclusion

SDRE patients are treated with AED polytherapy for all of the 3-year follow-up period. They are hospitalized more frequently than the general population and show increased morbidity levels and a sevenfold increase in mortality rate over 3 years. Further examination is required of ways in which new approaches to treatment could lead to better outcomes in severely affected patients.

Effect of Epilepsy on Families, Communities, and Society

The effect of epilepsy extends beyond those with the diagnosis and impacts families, communities and society. Caregiver and sibling quality of life is often negatively affected by frequent seizures, comorbid behavioral and sleep disorders and stigma surrounding the diagnosis. Furthermore, the negative effects can be magnified by individual coping styles and resources available to families of those with epilepsy. Beyond the family and immediate caregivers, epilepsy affects local communities by drawing additional resources from education systems. The direct costs of caring for an individual with epilepsy and the indirect costs associated with decreased productivity place financial strain on individuals and health care systems throughout the world. This review details factors affecting family and caregiver quality of life and provides several approaches through which health care providers may address these concerns. Furthermore, we examine the financial effect of epilepsy on society and review emerging strategies to lessen health care use for individuals with epilepsy.

The direct costs of epilepsy in Russia. A prospective cost-of-illness study from a single center in Moscow

OBJECTIVE

The objective of this study was to investigate prospectively the direct costs of epilepsy in Russia, taking a patient perspective and a bottom-up approach.

METHODS

The study was conducted in adolescents and adults with epilepsy seen in the ambulatory services of a city hospital in Moscow. Patients were assigned to different prognostic categories: newly diagnosed epilepsy; epilepsy in remission for 2+years; epilepsy in remission for <2years or with occasional seizures; active, nondrug-resistant epilepsy; drug-resistant epilepsy; and drug-resistant epilepsy in surgical candidates. Patients were followed prospectively for 12months. Demographic and clinical features at admission were collected and correlated with costs. Cost estimates were based on the Russian National Health Service perspective and its implementation in Moscow. Cost items included drugs and laboratory/instrumental tests. The costs per patient were calculated for the entire sample and for each prognostic category separately. Univariate and multivariate analyses were performed.

RESULTS

Included were 738 patients (393 men, 345 women aged 14-85years). The median annual cost/patient was €955 (IQR 521-2134; range 51-10,904). The median cost of drugs was €643 (IQR 288-1866; range 0-9960), and the median cost of laboratory/instrumental testing was €202 (IQR 160-270; range 20-1217). Mean costs varied across prognostic categories ranging from €782 in newly diagnosed patients to €3777 in patients with drug-resistant epilepsy. Mean (SD) hospital costs ranged from €646.7 (109.0) in patients with occasional seizures to €950.0 (28.3) in surgical candidates. Independent predictors of total costs were younger age at diagnosis, disability status, generalized seizures, multiple seizure types, seizure severity, and etiology.

SIGNIFICANCE

The cost of epilepsy in Moscow varies significantly depending on disease characteristics and response to drug treatment.

Neurologist adherence to clinical practice guidelines and costs in patients with newly diagnosed and chronic epilepsy in Germany

PURPOSE

The aim of this study was to evaluate physician adherence to the German Neurological Society guidelines of 2008 regarding initial monotherapy and to determine the cost-of-illness in epilepsy.

METHODS

This was an observational cohort study using health data routinely collected at 55 outpatient neurology practices throughout Germany (NeuroTransData network). Data on socioeconomic status, course of epilepsy, anticonvulsive treatment, and direct and indirect costs were recorded using practice software-based questionnaires.

RESULTS

One thousand five hundred eighty-four patients with epilepsy (785 male (49.6%); mean age: 51.3±18.1years) were enrolled, of whom 507 were newly diagnosed. Initial monotherapy was started according to authorization status in 85.9%, with nonenzyme-inducing drugs in 94.3% of all AEDs. Drugs of first choice by guideline recommendations were used in 66.5%. Total annual direct costs in the first year amounted to €2194 (SD: €4273; range: €55-43,896) per patient, with hospitalization (59% of total direct costs) and anticonvulsants (30%) as the main cost factors. Annual total direct costs decreased by 29% to €1572 in the second year, mainly because of a 59% decrease in hospitalization costs. The use of first choice AEDs did not influence costs. Chronic epilepsy was present in 1077 patients, and total annual direct costs amounted to €1847 per patient, with anticonvulsants (51.0%) and hospitalization (41.0%) as the main cost factors. Potential cost-driving factors in these patients were active epilepsy and focal epilepsy syndrome.

CONCLUSION

This study shows excellent physician adherence to guidelines regarding initial monotherapy in adults with epilepsy. Newly diagnosed patients show higher total direct and hospital costs in the first year upon diagnosis, but these are not influenced by adherence to treatment guidelines.

Health care utilization and outpatient, out-of-pocket costs for active convulsive epilepsy in rural northeastern South Africa: a cross-sectional Survey

Background

Epilepsy is a common neurological disorder, with over 80 % of cases found in low- and middle-income countries (LMICs). Studies from high-income countries find a significant economic burden associated with epilepsy, yet few studies from LMICs, where out-of-pocket costs for general healthcare can be substantial, have assessed out-of-pocket costs and health care utilization for outpatient epilepsy care.

Methods

Within an established health and socio-demographic surveillance system in rural South Africa, a questionnaire to assess self-reported health care utilization and time spent traveling to and waiting to be seen at health facilities was administered to 250 individuals, previously diagnosed with active convulsive epilepsy. Epilepsy patients’ out-of-pocket, medical and non-medical costs and frequency of outpatient care visits during the previous 12-months were determined.

Results

Within the last year, 132 (53 %) individuals reported consulting at a clinic, 162 (65 %) at a hospital and 34 (14 %) with traditional healers for epilepsy care. Sixty-seven percent of individuals reported previously consulting with both biomedical caregivers and traditional healers. Direct outpatient, median costs per visit varied significantly (p < 0.001) between hospital (2010 International dollar ($) 9.08; IQR: $6.41-$12.83) and clinic consultations ($1.74; IQR: $0-$5.58). Traditional healer fees per visit were found to cost $52.36 (IQR: $34.90-$87.26) per visit. Average annual outpatient, clinic and hospital out-of-pocket costs totaled $58.41. Traveling to and from and waiting to be seen by the caregiver at the hospital took significantly longer than at the clinic.

Conclusions

Rural South Africans with epilepsy consult with both biomedical caregivers and traditional healers for both epilepsy and non-epilepsy care. Traditional healers were the most expensive mode of care, though utilized less often. While higher out-of-pocket costs were incurred at hospital visits, more people with ACE visited hospitals than clinics for epilepsy care. Promoting increased use and effective care at clinics and reducing travel and waiting times could substantially reduce the out-of-pocket costs of outpatient epilepsy care.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1460-0) contains supplementary material, which is available to authorized users.

Vaccinating Italian infants with a new multicomponent vaccine (Bexsero®) against meningococcal B disease: A cost-effectiveness analysis

The European Medicines Agency has approved a multicomponent serogroup B meningococcal vaccine (Bexsero®) for use in individuals of 2 months of age and older. A cost-effectiveness analysis (CEA) from the societal and Italian National Health Service perspectives was performed in order to evaluate the impact of vaccinating Italian infants less than 1 y of age with Bexsero®, as opposed to non-vaccination. The analysis was carried out by means of Excel Version 2011 and the TreeAge Pro® software Version 2012. Two basal scenarios that differed in terms of disease incidence (official and estimated data to correct for underreporting) were considered. In the basal scenarios, we considered a primary vaccination cycle with 4 doses (at 2, 4, 6 and 12 months of age) and 1 booster dose at the age of 11 y, the societal perspective and no cost for death. Sensitivity analyses were carried out in which crucial variables were changed over probable ranges. In Italy, on the basis of official data on disease incidence, vaccination with Bexsero® could prevent 82.97 cases and 5.61 deaths in each birth cohort, while these figures proved to be three times higher on considering the estimated incidence. The results of the CEA showed that the Incremental Cost Effectiveness Ratio (ICER) per QALY was €109,762 in the basal scenario if official data on disease incidence are considered and €26,599 if estimated data are considered. The tornado diagram indicated that the most influential factor on ICER was the incidence of disease. The probability of sequelae, the cost of the vaccine and vaccine effectiveness also had an impact. Our results suggest that vaccinating infants in Italy with Bexsero® has the ability to significantly reduce meningococcal disease and, if the probable underestimation of disease incidence is considered, routine vaccination is advisable.

Addressing the burden of epilepsy: Many unmet needs

Epilepsy is a heterogeneous clinical condition characterized by recurrent unprovoked seizures, their causes and complications. The incidence, prevalence and mortality of epilepsy vary with age, place and time contributing to a variable extent to the burden of the disease. Diagnostic misclassification may have strong impact on personal and societal reflections of the disease in light of its clinical manifestations and the need for chronic treatment. Epilepsy accounts for a significant proportion of the world's disease burden ranking fourth after tension-type headache, migraine and Alzheimer disease. Among neurological diseases, it accounts for the highest disability-adjusted life year rates both in men and in women. Although epilepsy is self-remitting in up to 50% of cases, variable long-term prognostic patterns can be identified based on the response to the available treatments. Epilepsy carries an overall increased risk of premature mortality with variable estimates across countries. Premature mortality predominates in patients aged less than 50 years, with epilepsies due to structural/metabolic conditions, with generalized tonic-clonic seizures, and seizures not remitting under treatment. Among deaths directly attributable to epilepsy or seizures, included are sudden unexpected death in epilepsy (SUDEP), status epilepticus, accidents, drowning, unintentional injuries, and suicide. Somatic and psychiatric disorders prevail in patients with epilepsy than in people without epilepsy. Asthma, migraine and cerebral tumors tend to occur more frequently in younger adults while cardiovascular disorders, stroke, dementia and meningioma predominate in the elderly. As being a fairly common clinical condition affecting all ages and requiring long-term (sometimes lifelong) treatment, epilepsy carries high health care costs for the society. Direct costs peak in the first year after diagnosis and then vary according to the severity of the disease, the response to treatment, and the presence of comorbidity. Although in several countries the costs of epilepsy are met by the national health systems, out-of-pocket costs may be a relevant fraction of the overall costs, especially in countries where the public management of health care is suboptimal or non-existent. Epilepsy strongly affects patients' independence, psychological health and emotional adjustment. Epilepsy impairs all aspects of health-related quality of life. Awareness and attitudes of the public about epilepsy may significantly affect the burden of the disease. All these factors add to the burden of the disease. However, many of the factors implicated in the onset of epilepsy, its course and treatment can be favorably addressed with appropriate strategic plans. More research is needed to investigate and manage the medical and psychosocial implications of epilepsy.

Can the Direct Medical Cost of Chronic Disease Be Transferred across Different Countries? Using Cost-of-Illness Studies on Type 2 Diabetes, Epilepsy and Schizophrenia as Examples

Objectives

To systematically review cost of illness studies for schizophrenia (SC), epilepsy (EP) and type 2 diabetes mellitus (T₂DM) and explore the transferability of direct medical cost across countries.

Methods

A comprehensive literature search was performed to yield studies that estimated direct medical costs. A generalized linear model (GLM) with gamma distribution and log link was utilized to explore the variation in costs that accounted by the included factors. Both parametric (Random-effects model) and non-parametric (Boot-strapping) meta-analyses were performed to pool the converted raw cost data (expressed as percentage of GDP/capita of the country where the study was conducted).

Results

In total, 93 articles were included (40 studies were for T₂DM, 34 studies for EP and 19 studies for SC). Significant variances were detected inter- and intra-disease classes for the direct medical costs. Multivariate analysis identified that GDP/capita (p<0.05) was a significant factor contributing to the large variance in the cost results. Bootstrapping meta-analysis generated more conservative estimations with slightly wider 95% confidence intervals (CI) than the parametric meta-analysis, yielding a mean (95%CI) of 16.43% (11.32, 21.54) for T₂DM, 36.17% (22.34, 50.00) for SC and 10.49% (7.86, 13.41) for EP.

Conclusions

Converting the raw cost data into percentage of GDP/capita of individual country was demonstrated to be a feasible approach to transfer the direct medical cost across countries. The approach from our study to obtain an estimated direct cost value along with the size of specific disease population from each jurisdiction could be used for a quick check on the economic burden of particular disease for countries without such data.

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.

Costs of epilepsy and cost-driving factors in children, adolescents, and their caregivers in Germany

OBJECTIVE

To provide first data on the cost of epilepsy and cost-driving factors in children, adolescents, and their caregivers in Germany.

METHODS

A population-based, cross-sectional sample of consecutive children and adolescents with epilepsy was evaluated in the states of Hessen and Schleswig-Holstein (total of 8.796 million inhabitants) in all health care sectors in 2011. Data on socioeconomic status, course of epilepsy, and direct and indirect costs were recorded using patient questionnaires.

RESULTS

We collected data from 489 children and adolescents (mean age ± SD 10.4 ± 4.2 years, range 0.5-17.8 years; 264 [54.0%] male) who were treated by neuropediatricians (n = 253; 51.7%), at centers for social pediatrics ("Sozialpaediatrische Zentren," n = 110, 22.5%) and epilepsy centers (n = 126; 25.8%). Total direct costs summed up to €1,619 ± €4,375 per participant and 3-month period. Direct medical costs were due mainly to hospitalization (47.8%, €774 ± €3,595 per 3 months), anticonvulsants (13.2%, €213 ± €363), and ancillary treatment (9.1%, €147 ± €344). The total indirect costs amounted to €1,231 ± €2,830 in mothers and to €83 ± €593 in fathers; 17.4% (n = 85) of mothers and 0.6% (n = 3) of fathers reduced their working hours or quit work because of their child's epilepsy. Independent cost-driving factors were younger age, symptomatic cause, and polytherapy with anticonvulsants. Older age, active epilepsy, symptomatic cause, and polytherapy were independent predictors of higher antiepileptic drug (AED) costs, whereas younger age, longer epilepsy duration, symptomatic cause, disability, and parental depression were independent predictors for higher indirect costs.

SIGNIFICANCE

Treatment of children and adolescents with epilepsy is associated with high direct costs due to frequent inpatient admissions and high indirect costs due to productivity losses in mothers. Direct costs are age-dependent and higher in patients with symptomatic epilepsy and polytherapy. Indirect costs are higher in the presence of a child's disability and parental depression.

Health Technology Assessment report on the presurgical evaluation and surgical treatment of drug-resistant epilepsy

PURPOSE

Epilepsy is a neurologic disorder with major social impact. Surgery is a valuable option in patients who are not responding to antiepileptic drugs. The literature reports demonstrate that a proportion ranging from 40 to 100% of patients with epilepsy achieve seizure remission after surgery. A presurgical evaluation (clinical and instrumental) must be performed in all patients with drug-resistant epilepsy to assess their suitability for surgical intervention. Health Technology Assessment (HTA) represents a modern approach to the analysis of technologies used for health care. HTA could be considered a bridge between science that produces evidence and the decisions that can be taken on the basis of that evidence at different levels of the health care system. The aim of this study is the HTA of epilepsy surgery including clinical, ethical, social, and economic features.

METHODS

The present study includes an analysis of the diagnostic and surgical workup performed at the Italian centers for the diagnosis and treatment of drug-resistant epilepsy (DRE). The study includes the following issues: (1) social, ethical impact, and costs of the disease; (2) clinical results, efficacy, and safety of surgery; (3) ethics and quality of life after surgery; and (4) economic impact and productivity regained after surgery. The cost of managing a patient with DRE included in the presurgical study was estimated by the bottom-up microcosting technique that starts from a detailed collection of data on consumption of resources and full costing. The phases analyzed were (1) noninvasive diagnostic workup; (2) neurosurgical intervention; and (3) follow-up.

KEY FINDINGS

The literature reports indicate epilepsy surgery as an effective treatment both on clinical results and on ethical, social, and quality of life aspects. The workup including the noninvasive presurgical study followed by surgery has a total cost of €20,827. Management of short-term follow-up increases the overhead to €22,291 at the first year, and then to €23,571 after 5 years. According to the estimates made in this survey, funding based on diagnosis-related group (DRG) tariff for the noninvasive diagnostic stage involving hospital admission is not remunerative in Italy either at regional or national levels. Effectively the difference between full cost and DRG has a delta of €3,402 and €2,537 respectively. The total cost of the presurgical, surgical, and follow-up evaluation is not remunerative for €10,554 (national data).

SIGNIFICANCE

Economic surveys in Italy have shown that surgery for DRE is an advantageous treatment from the standpoint of third-party payers and is cost-effective for society. DRE presurgical evaluation and surgery are not remunerative either at regional or national levels.

Trends in resource utilization and prescription of anticonvulsants for patients with active epilepsy in Germany

This study evaluated trends in the resource use of patients with active epilepsy over a 5-year period at an outpatient clinic of a German epilepsy center. Two cross-sectional cohorts of consecutive adults with active epilepsy were evaluated over a 3-month period in 2003 and 2008. Data on socioeconomic status, course of epilepsy, as well as direct and indirect costs were recorded using validated patient questionnaires. We enrolled 101 patients in 2003 and 151 patients in 2008. In both cohorts, 76% of the patients suffered from focal epilepsy, and the majority was on antiepileptic drug (AED) polytherapy (mean AED number: 1.7 (2003), 1.8 (2008)). We calculated epilepsy-specific costs of € 2955 in 2003 and € 3532 in 2008 per 3 months per patient. Direct medical costs were mainly due to anticonvulsants in 2003 (59.4% of total direct costs, 34.0% in 2008) and to hospitalization in 2008 (46.9% of total direct costs, 27.7% in 2003). The proportion of enzyme-inducing anticonvulsants and 'old' AEDs decreased between 2003 and 2008. Indirect costs of € 1689 and € 1847 were mainly due to early retirement (48.4%; 46.0% of total indirect costs in 2003; 2008), unemployment (26.1%; 24.2%), and days off due to seizures (25.5%; 29.8%). This study showed a shift in distribution of direct cost components with increased hospital costs as well as a cost-neutral increase in the prescription of 'newer' AEDs. The amount and distribution of indirect cost components remained unchanged.

Evaluation of health-care utilization among adult patients with epilepsy in Germany

This study evaluated the resource use of patients with epilepsy in the German district of Marburg-Biedenkopf. A cross-sectional cohort of consecutive adults with epilepsy, irrespective of seizure severity, duration of illness and epilepsy syndrome, was investigated in all health-care sectors. Costs of inpatient and outpatient treatment were derived from billing data of participating hospitals and office-based physicians. Data on socioeconomic status, course of epilepsy and further direct and indirect costs were recorded using patient questionnaires. We enrolled 366 patients from the district of Marburg-Biedenkopf and calculated annual epilepsy-specific costs of €7738 per patient. Direct costs contributed 31.1% (€2406) and indirect costs 68.9% (€5332) of the total costs. Direct medical costs were mainly due to hospitalization (33.2% of total direct costs) and anticonvulsants (26.7%). Costs of admissions were due to status epilepticus (24.4%), video-EEG monitoring (14.8%), newly diagnosed patients (14.4%) and seizure-related injuries (8.8%). Indirect costs were mainly due to early retirement (38.0%), unemployment (35.9%) and days off due to seizures (26.2%). The mean costs of epilepsy found in our study were lower than those found in studies conducted at European epilepsy centers due to the inclusion of patients in all health-care sectors.

Cost of disorders of the brain in Europe 2010

BACKGROUND

The spectrum of disorders of the brain is large, covering hundreds of disorders that are listed in either the mental or neurological disorder chapters of the established international diagnostic classification systems. These disorders have a high prevalence as well as short- and long-term impairments and disabilities. Therefore they are an emotional, financial and social burden to the patients, their families and their social network. In a 2005 landmark study, we estimated for the first time the annual cost of 12 major groups of disorders of the brain in Europe and gave a conservative estimate of €386 billion for the year 2004. This estimate was limited in scope and conservative due to the lack of sufficiently comprehensive epidemiological and/or economic data on several important diagnostic groups. We are now in a position to substantially improve and revise the 2004 estimates. In the present report we cover 19 major groups of disorders, 7 more than previously, of an increased range of age groups and more cost items. We therefore present much improved cost estimates. Our revised estimates also now include the new EU member states, and hence a population of 514 million people.

AIMS

To estimate the number of persons with defined disorders of the brain in Europe in 2010, the total cost per person related to each disease in terms of direct and indirect costs, and an estimate of the total cost per disorder and country.

METHODS

The best available estimates of the prevalence and cost per person for 19 groups of disorders of the brain (covering well over 100 specific disorders) were identified via a systematic review of the published literature. Together with the twelve disorders included in 2004, the following range of mental and neurologic groups of disorders is covered: addictive disorders, affective disorders, anxiety disorders, brain tumor, childhood and adolescent disorders (developmental disorders), dementia, eating disorders, epilepsy, mental retardation, migraine, multiple sclerosis, neuromuscular disorders, Parkinson's disease, personality disorders, psychotic disorders, sleep disorders, somatoform disorders, stroke, and traumatic brain injury. Epidemiologic panels were charged to complete the literature review for each disorder in order to estimate the 12-month prevalence, and health economic panels were charged to estimate best cost-estimates. A cost model was developed to combine the epidemiologic and economic data and estimate the total cost of each disorder in each of 30 European countries (EU27+Iceland, Norway and Switzerland). The cost model was populated with national statistics from Eurostat to adjust all costs to 2010 values, converting all local currencies to Euro, imputing costs for countries where no data were available, and aggregating country estimates to purchasing power parity adjusted estimates for the total cost of disorders of the brain in Europe 2010.

RESULTS

The total cost of disorders of the brain was estimated at €798 billion in 2010. Direct costs constitute the majority of costs (37% direct healthcare costs and 23% direct non-medical costs) whereas the remaining 40% were indirect costs associated with patients' production losses. On average, the estimated cost per person with a disorder of the brain in Europe ranged between €285 for headache and €30,000 for neuromuscular disorders. The European per capita cost of disorders of the brain was €1550 on average but varied by country. The cost (in billion €PPP 2010) of the disorders of the brain included in this study was as follows: addiction: €65.7; anxiety disorders: €74.4; brain tumor: €5.2; child/adolescent disorders: €21.3; dementia: €105.2; eating disorders: €0.8; epilepsy: €13.8; headache: €43.5; mental retardation: €43.3; mood disorders: €113.4; multiple sclerosis: €14.6; neuromuscular disorders: €7.7; Parkinson's disease: €13.9; personality disorders: €27.3; psychotic disorders: €93.9; sleep disorders: €35.4; somatoform disorder: €21.2; stroke: €64.1; traumatic brain injury: €33.0. It should be noted that the revised estimate of those disorders included in the previous 2004 report constituted €477 billion, by and large confirming our previous study results after considering the inflation and population increase since 2004. Further, our results were consistent with administrative data on the health care expenditure in Europe, and comparable to previous studies on the cost of specific disorders in Europe. Our estimates were lower than comparable estimates from the US.

DISCUSSION

This study was based on the best currently available data in Europe and our model enabled extrapolation to countries where no data could be found. Still, the scarcity of data is an important source of uncertainty in our estimates and may imply over- or underestimations in some disorders and countries. Even though this review included many disorders, diagnoses, age groups and cost items that were omitted in 2004, there are still remaining disorders that could not be included due to limitations in the available data. We therefore consider our estimate of the total cost of the disorders of the brain in Europe to be conservative. In terms of the health economic burden outlined in this report, disorders of the brain likely constitute the number one economic challenge for European health care, now and in the future. Data presented in this report should be considered by all stakeholder groups, including policy makers, industry and patient advocacy groups, to reconsider the current science, research and public health agenda and define a coordinated plan of action of various levels to address the associated challenges.

RECOMMENDATIONS

Political action is required in light of the present high cost of disorders of the brain. Funding of brain research must be increased; care for patients with brain disorders as well as teaching at medical schools and other health related educations must be quantitatively and qualitatively improved, including psychological treatments. The current move of the pharmaceutical industry away from brain related indications must be halted and reversed. Continued research into the cost of the many disorders not included in the present study is warranted. It is essential that not only the EU but also the national governments forcefully support these initiatives.

Utilization and costs of antiepileptic drugs in the elderly: still an unsolved issue

The aging of the general population in industrialized countries has brought to public attention the increasing incidence of age- and aging-related clinical conditions. Management of multiple and chronic disorders has become a more important issue for healthcare authorities because of increasing requests for medical assistance, the greater numbers of drugs required and drug interactions reported, and the increase in treatment-related costs. Epilepsy is a chronic clinical condition affecting both sexes and all ages with a worldwide distribution. The incidence of epilepsy, after childhood, increases with age and the cumulative risk of epilepsy by 80 years of age ranges from 1.3% to 4% in different study populations. Although the issues for people with epilepsy are similar for older and younger adults, the elderly may require more attention with regard to selection of antiepileptic drugs (AEDs) than younger patients. Elderly patients with newly diagnosed epilepsy are more likely to remain seizure-free on AED therapy than younger populations; however, the toxicity of AEDs in elderly patients is ill-defined because seizures may be difficult to recognize in this group and the symptoms and signs of toxicity can be attributed to other causes. Moreover, elderly people have chronic clinical conditions and are more likely to be taking medications that could possibly interfere with AEDs.Some older AEDs such as phenobarbital and phenytoin should not be used in the elderly because of their pharmacokinetic and pharmacodynamic profiles. There is no evidence that new AEDs, despite their better tolerability profiles, are advantageous in terms of attaining freedom from seizures compared with older agents.Older AEDs are much less expensive than the new compounds and, with some exceptions, appear to be more cost effective. New AEDs may be cost effective only in patients who are not able to tolerate or who are resistant to older compounds or when the use of an older drug is contraindicated. However, there are no cost-effectiveness studies in the elderly and further evidence is needed to confirm these assumptions.

Economic analysis of newer antiepileptic drugs

In the last 20 years, several second-generation antiepileptic drugs (AEDs) have been marketed. These newer drugs are expensive and have no established superiority over the first-generation compounds in terms of efficacy when used as monotherapy. A systematic review of economic studies dealing with the newer AEDs has been performed to put these drugs in a wider perspective. A number of economic analysis studies of second-generation AEDs have examined these compounds as monotherapy or adjunctive therapy. Almost all monotherapy studies showed newer AEDs as having similar effectiveness but significantly higher acquisition costs than first-generation drugs. The evidence from adjunctive therapy studies was more conflicting. Lamotrigine appeared to be a cost-effective drug when higher thresholds were used, or when savings were defined by the cost of surgery. Levetiracetam also appeared to be cost effective when the costs of surgical investigation were discounted.In a decision model that included quantification of the uncertainty associated with the decision regarding the cost effectiveness of AEDs, second-generation drugs used as monotherapy for newly diagnosed partial epilepsy produced similar benefits but were more expensive than older drugs. The newer AEDs were more effective but more expensive than existing monotherapies in patients with refractory partial epilepsy, but may be cost effective at higher thresholds, and continue to be cost effective in patients responding to the assigned drug. In patients with newly diagnosed generalized epilepsy, valproate was more cost effective than lamotrigine.The results of current economic studies are difficult to assess and compare because of a number of methodological drawbacks. Future studies should be implemented using a standardized approach to define the costs and outcomes of representative cohorts of patients with newly diagnosed epilepsy recruited from different countries and followed prospectively.

Estimating the cost of epilepsy in Europe: a review with economic modeling

PURPOSE

Based on available epidemiologic, health economic, and international population statistics literature, the cost of epilepsy in Europe was estimated.

METHODS

Europe was defined as the 25 European Union member countries, Iceland, Norway, and Switzerland. Guidelines for epidemiological studies on epilepsy were used for a case definition. A bottom-up prevalence-based cost-of-illness approach, the societal perspective for including the cost items, and the human capital approach as valuation principle for indirect costs were used. The cost estimates were based on selected studies with common methodology and valuation principles.

RESULTS

The estimated prevalence of epilepsy in Europe in 2004 was 4.3-7.8 per 1,000. The estimated total cost of the disease in Europe was euro15.5 billion in 2004, indirect cost being the single most dominant cost category (euro8.6 billion). Direct health care costs were euro2.8 billion, outpatient care comprising the largest part (euro1.3 billion). Direct nonmedical cost was euro4.2 billion. That of antiepileptic drugs was euro400 million. The total cost per case was euro2,000-11,500 and the estimated cost per European inhabitant was euro33.

CONCLUSIONS

Epilepsy is a relevant socioeconomic burden at individual, family, health services, and societal level in Europe. The greater proportion of such burden is outside the formal health care sector, antiepileptic drugs representing a smaller proportion. Lack of economic data from several European countries and other methodological limitations make this report an initial estimate of the cost of epilepsy in Europe. Prospective incidence cost-of-illness studies from well-defined populations and common methodology are encouraged.

Cross-country measures for monitoring epilepsy care

PURPOSE

The International League Against Epilepsy (ILAE) Commission on Healthcare Policy in consultation with the World Health Organization (WHO) examined the applicability and usefulness of various measures for monitoring epilepsy healthcare services and systems across countries. The goal is to provide planners and policymakers with tools to analyze the impact of healthcare services and systems and evaluate efforts to improve performance.

METHODS

Commission members conducted a systematic literature review and consulted with experts to assess the nature, strengths, and limitations of the treatment gap and resource availability measures that are currently used to assess the adequacy of epilepsy care. We also conducted a pilot study to determine the feasibility and applicability of using new measures to assess epilepsy care developed by the WHO including Disability-Adjusted Life Years (DALYs), responsiveness, and financial fairness.

RESULTS

The existing measures that are frequently used to assess the adequacy of epilepsy care focus on structural or process factors whose relationship to outcomes are indirect and may vary across regions. The WHO measures are conceptually superior because of their breadth and connection to articulated and agreed upon outcomes for health systems. However, the WHO measures require data that are not readily available in developing countries and most developed countries as well.

CONCLUSION

The epilepsy field should consider adopting the WHO measures in country assessments of epilepsy burden and healthcare performance whenever data permit. Efforts should be made to develop the data elements to estimate the measures.

Direct and Indirect Costs of Refractory Epilepsy in a Tertiary Epilepsy Center in Germany

PURPOSE

There are only few studies on the costs of epilepsy in Germany. Therefore, we performed a pilot study to estimate the direct and indirect costs of refractory epilepsy in a German epilepsy center.

METHODS

A "prevalence-based," cross-sectional convenience sample of adults with active epilepsy attending the outpatient clinic of our tertiary epilepsy center was evaluated. Seizure-free patients and patients presenting with their first seizure were excluded. Direct and indirect costs were prospectively recorded over a three-month period using questionnaires and a patient diary. Cost driving factors were identified.

RESULTS

One hundred one patients were included (40.7+/-15.2 years; disease duration: 18.1+/-15.3 years; 6 patients had focal epilepsy with simple partial seizures only, 28 with complex partial seizures, 43 with secondarily generalized tonic-clonic seizures; 20 had idiopathic generalized epilepsy with generalized tonic-clonic seizures). The total costs of epilepsy per patient were in average euro 2610+/-4200 over the three-month period. Direct cost contributed 39% to the total costs. Costs of anticonvulsant medication were the main contributor to the direct costs while indirect costs were caused mainly by losses due to early retirement. Cost driving factors included higher seizure frequency, longer disease duration, ictal falls, and situationally inappropriate complex behavior during or after the seizure.

CONCLUSIONS

Indirect costs were higher than direct costs in adult patients with active epilepsy attending a German epilepsy center. Medication contributed the most to the direct costs and early retirement was the main factor for the indirect costs. The costs of poorly controlled epilepsy in this German study were above average of the European costs of epilepsy.