The contribution of tertiary centers to the quality of the diagnosis and treatment of epilepsy. Osservatorio Regionale per l'Epilessia (OREp), Lombardy

Care delivery and self management strategies for adults with epilepsy

BACKGROUND

Researchers have criticised epilepsy care for adults for its lack of impact, stimulating the development of various service models and strategies to respond to perceived inadequacies.

OBJECTIVES

To assess the effects of any specialised or dedicated intervention beyond that of usual care in adults with epilepsy.

SEARCH METHODS

For the latest update of this review, we searched the Cochrane Epilepsy Group Specialized Register (9 December 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (2013, Issue 11), MEDLINE (1946 to June 2013), EMBASE (1988 to June 2013), PsycINFO (1887 to December 2013) and CINAHL (1937 to December 2013). In addition, we contacted experts in the field to seek information on unpublished and ongoing studies, checked the websites of epilepsy organisations and checked the reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials, controlled or matched trials, cohort studies or other prospective studies with a control group, and time series studies.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted all data, and assessed the quality of all included studies.

MAIN RESULTS

Our review included 18 different studies of 16 separate interventions, which we classified into seven distinct groups. Most of the studies have methodological weaknesses, and many results from other analyses within studies need to be interpreted with caution because of study limitations. Consequently, there is currently limited evidence for the effectiveness of interventions to improve the health and quality of life in people with epilepsy. It was not possible to combine study results in a meta-analysis because of the heterogeneity of outcomes, study populations, interventions and time scales across the studies.

AUTHORS' CONCLUSIONS

Two intervention types, the specialist epilepsy nurse and self management education, have some evidence of benefit. However, we did not find clear evidence that other service models substantially improve outcomes for adults with epilepsy. It is also possible that benefits are situation specific and may not apply to other settings. These studies included only a small number of service providers whose individual competence or expertise may have had a significant impact on outcomes. At present it is not possible to advocate any single model of service provision.

Validation of healthcare administrative data for the diagnosis of epilepsy

BACKGROUND

Administrative databases have become an important tool to monitor diseases. Patients with epilepsy could be traced using disease-specific codes and prescriptions, but formal validation is required to obtain an accurate case definition. The aim of the study was to correlate administrative data on epilepsy with an independent source of patients with epilepsy in a district of Lombardy, Northern Italy, from 2000 to 2008.

METHODS

Data of nearly 320 600 inhabitants in the district of Lecco collected from the Drug Administrative Database of the Lombardy Region were analysed. Among them were included patients who fulfilled the International Classification of Diseases 9 (ICD-9) codes and/or the disease-specific exemption code for epilepsy and those who had at least one EEG record and took antiepileptic drugs (AEDs) as monotherapy or in variable combinations. To ascertain epilepsy cases, 11 general practitioners (GPs) with 15 728 affiliates were contacted. Multiple versions of the diagnostic algorithm were developed using different logistic regression models and all combinations of the four independent variables.

RESULTS

Among the GP affiliates, 71 (4.5/1000) had a gold standard diagnosis of epilepsy. The best and most conservative algorithm included EEG and selected treatment schedules and identified 61/71 patients with epilepsy (sensitivity 85.9%, CI 76.0% to 92.2%) and 15 623/15 657 patients without epilepsy (specificity 99.8%,CI 99.7% to 99.8%). The positive and negative predictive values were 64.2% and 99.9%. Sensitivity (86.7%) and the positive predictive value (68.4%) increased only slightly when patients with single seizures were included.

CONCLUSIONS

A diagnostic algorithm including EEG and selected treatment schedules is only moderately sensitive for the detection of epilepsy and seizures. These findings apply only to the Northern Italian scenario.

Care delivery and self-management strategies for adults with epilepsy

BACKGROUND

Epilepsy care has been criticised for its lack of impact. Various service models and strategies have been developed in response to perceived inadequacies in care provision.

OBJECTIVES

To compare the effectiveness of any specialised or dedicated intervention for the care of adults with epilepsy to the effectiveness of usual care.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2006), MEDLINE (1966 to May 2006), EMBASE (1988 to May 2006), PsychINFO (1806 to May 2006) and CINAHL (1982 to May 2006).

SELECTION CRITERIA

Randomised controlled trials, controlled or matched trials, cohort studies or other prospective studies with a control group, or time series studies.

DATA COLLECTION AND ANALYSIS

Each review author independently selected studies, extracted data and assessed the quality of included studies.

MAIN RESULTS

There are 13 trials and 16 reports included in this review. Seven distinct groups of interventions were identified: seven papers reported on five trials of specialist epilepsy nurses. Of the 13 trials, at least three (four reports) have methodological weaknesses, and some of the results from other analyses within studies need to be interpreted with caution because of limiting factors in the studies. Consequently, there is currently limited evidence for the effectiveness of interventions to improve the health and life quality of people with epilepsy. It was not possible to combine study results in a meta-analysis because of the heterogeneity of outcomes, study populations, interventions, and time scales across the studies.

AUTHORS' CONCLUSIONS

Two intervention types, the specialist epilepsy nurse and self-management education, have some evidence of benefit. However, we did not find clear evidence that other service models substantially improve outcomes for adults with epilepsy. It is also possible that benefits are situation specific and may not generalise to other settings. These studies included only a small number of service providers whose individual competence or expertise may have had a significant impact on outcomes. At present it is not possible to advocate any single model of service provision.

The costs of epilepsy in Italy: a prospective cost-of-illness study in referral patients with disease of different severity

PURPOSE

[corrected] Epilepsy poses a considerable economic burden on society. However, information is insufficient on the comparative costs of different disease varieties. The purpose of this study was to compare the direct costs of epilepsy in referral patients with disease of different severity and duration.

METHODS

Patients with newly diagnosed epilepsy (NDE), seizure remission (SR), occasional seizures (OS), frequent non-drug-resistant (NDR) and drug-resistant (DR) seizures, and surgical candidates (SC) from 14 epilepsy centers were the target population. All patients were followed prospectively for 12 months and all medical and paramedical contacts for diagnostic and therapeutic services were noted with details, using ad-hoc diaries and semistructured questionnaires.

RESULTS

The study population comprised 525 consecutive children and adults with partial (68%), generalized (25%) and undetermined epilepsy (4%) as follows: NDE 70; SR 131; OS 108; NDR 101; DR 107; SC 8. Ambulatory visits (mean 2.8 per patient per year) were the leading service in all groups, followed by EEG recordings (1.8) and biochemical assays (1.1). At entry, the commonest drugs were carbamazepine (50%), valproate (37%), phenobarbital (21%), vigabatrin (14%) and lamotrigine (11%). New antiepileptic drugs (AED) were used increasingly with the severity of the disease. The total annual costs varied significantly across groups: 3945 Euro (SC), 2198 Euro (DR), 1626 Euro (NDR), 1002 Euro (NDE), 558 Euro (OS), 412 Euro (SR). The main item of expenditure was hospital stay (including day-hospital), followed by drug treatment and outpatient visits. The costs of outpatient services, hospital services and drugs varied significantly across groups.

CONCLUSIONS

The direct costs of epilepsy vary significantly depending on the severity of the disease and the response to treatment. Hospital admissions and drugs are the commonest items of expenditure.

Newly diagnosed unprovoked epileptic seizures: presentation at diagnosis in CAROLE study. Coordination Active du Réseau Observatoire Longitudinal de l' Epilepsie

PURPOSE

We describe first unprovoked seizures and newly diagnosed epilepsies at initial presentation, with a special emphasis on epilepsy syndromes, in a large cohort recruited in the mid-1990s in France.

METHODS

The French Foundation for Research on Epilepsy set up a network to conduct a prospective study of patients with newly diagnosed unprovoked seizures. Information was provided by 243 child or adult neurologists. Four neurologists classified each case according to the International League Against Epilepsy (ILAE) criteria. First-seizure patients and patients with previously undiagnosed seizures were compared.

RESULTS

Between May 1, 1995, and June 30, 1996, 1,942 patients aged from 1 month to 95 years were identified: 926 (47.7%) with a single seizure and 1,016 (52.3%) with newly diagnosed epilepsy. All but 17 patients had EEGs. In the first-seizure and newly-diagnosed-epilepsy groups, neuroimaging studies were performed in 78.2 and 68.3% of patients, and medication prescribed in 54.1 and 89.6%, respectively. There were significant differences between the two groups with respect to age at onset and diagnosis, sex, etiology, several specific syndromes, as well as the type and presentation of initial seizure. In patients for whom the first seizure was convulsive, only sex, multiple seizures in a day or status epilepticus, and cryptogenic localization-related syndrome differed between the two groups.

CONCLUSIONS

Approximately half of patients who first came to attention for an unprovoked seizure already met epidemiologic criteria for epilepsy. There were significant differences between the types of patients with a first seizure and those with newly diagnosed epilepsy. One or several seizures at diagnosis did not influence the diagnostic assessment of the patients but had a strong influence on the initiation of treatment.