Development of an epilepsy-specific risk adjustment comorbidity index

High cardiorespiratory disease burden following a fracture among adults with intellectual disabilities

BACKGROUND

Adults with intellectual disabilities have a greater risk for fragility fractures that begin to accumulate early in the adult lifespan, which may contribute to accelerated health declines. The objective was to determine if fragility fractures were associated with an increased 2-year rate of cardiorespiratory diseases among adults with intellectual disabilities.

METHOD

This retrospective cohort study used nationwide administrative claims data from 01/01/2011-12/31/2016 from the Medicare fee-for-service database. 2-year incidence of cardiorespiratory diseases were compared between adults ≥18 years old with intellectual disabilities with (n = 6183) vs. without (n = 67,842) an incident fragility fracture after confounder adjustment using Cox regression.

RESULTS

Fracture at the vertebral column, hip, non-proximal femur, tibia/fibula, and multiple sites had an elevated hazard ratio (HR) compared to those with no fracture for pneumonia, respiratory failure, heart failure, and cerebrovascular disease (HR range, 1.15-2.09, all P < 0.05), while humerus and radius/ulna fracture were associated with an elevated HR for congestive heart failure and cerebrovascular disease (HR range, 1.38-1.72, all P < 0.05).

CONCLUSIONS

Fragility fractures were associated with an increased incidence of cardiorespiratory diseases among adults with intellectual disabilities.

Association Between Frailty and Antiseizure Medication Tolerability in Older Adults With Epilepsy

BACKGROUND AND OBJECTIVE

Frailty is an important aspect of biological aging, referring to the increased vulnerability of individuals with frailty to physical and psychological stressors. While older adults with epilepsy are an important and distinct clinical group, there are no data on frailty in this population. We hypothesize that frailty will correlate with the seizure frequency and especially the tolerability of antiseizure medications (ASMs) in older adults with epilepsy.

METHODS

We recruited individuals aged 60 years or older with active epilepsy from 4 Canadian hospital centers. We reported the seizure frequency in the 3 months preceding the interview, while ASM tolerability was quantified using the Liverpool Adverse Events Profile (LAEP). We applied 3 measures of frailty: grip strength as a measure of physical frailty, 1 self-reported score (Edmonton frail score [EFS]), and 1 scale completed by a healthcare professional (clinical frailty scale [CFS]). We also administered standardized questionnaires measuring levels of anxiety, depression, functional disability, and quality of life and obtained relevant clinical and demographic data.

RESULTS

Forty-three women and 43 men aged 60-93 years were recruited, 87% of whom had focal epilepsy, with an average frequency of 3.4 seizures per month. Multiple linear regression and zero-inflated negative binomial regression models showed that EFS and CFS scores were associated with decreased ASM tolerability, each point increase leading to 1.83 (95% CI: 0.67-4.30) and 2.49 (95% CI: 1.27-2.39) point increases on the LAEP scale, respectively. Neither the EFS and CFS scores nor grip strength were significantly associated with seizure frequency. The EFS was moderately correlated with depression, anxiety, quality of life, and functional disability, demonstrating the best construct validity among the 3 tested measures of frailty.

DISCUSSION

The EFS was significantly, both statistically and clinically, associated with ASM tolerability. It also showed multiple advantages in performance while assessing for frailty in older adults with epilepsy, when compared with the 2 other measures of frailty that we tested. Future studies must focus on what role the EFS during epilepsy diagnosis may play in ASM selection among older adults with epilepsy.

Multimorbidity in People with Epilepsy

Multimorbidity is an emerging priority in healthcare due to associations with the ageing population, frailty, polypharmacy, health and social care demands. It affects 60-70% of adults and 80% of children with epilepsy. Neurodevelopmental conditions are commonly seen in children with epilepsy, while cancer, cardiovascular and neurodegenerative conditions often afflict older people with epilepsy. Mental health problems are common across the lifespan. Genetic, environmental, social and lifestyle factors contribute to multimorbidity and its consequences. Multimorbid people with epilepsy (PWE) are at higher risk of depression and suicide, premature death, suffer lower health-related quality of life, and require more hospital admissions and health care costs. The best management of multimorbid PWE requires a paradigm shift from the traditional single disease-single comorbidity approach and a refocus on a person-centred approach. Improvements in health care must be informed by assessing the burden of multimorbidity associated with epilepsy, delineating disease clusters, and measuring the effects on health outcomes.

Management of epilepsy in older adults: A critical review by the ILAE Task Force on Epilepsy in the elderly

Older adults represent a highly heterogeneous population, with multiple diverse subgroups. Therefore, an individualized approach to treatment is essential to meet the needs of each unique subgroup. Most comparative studies focusing on treatment of epilepsy in older adults have found that levetiracetam has the best chance of long-term seizure freedom. However, there is a lack of studies investigating other newer generation antiseizure medications (ASMs). Although a number of randomized clinical trials have been performed on older adults with epilepsy, the number of participants studied was generally small, and they only investigated short-term efficacy and tolerability. Quality of life as an outcome is often missing but is necessary to understand the effectiveness and possible side effects of treatment. Prognosis needs to move beyond the focus on seizure control to long-term patient-centered outcomes. Dosing studies with newer generation ASMs are needed to understand which treatments are the best in the older adults with different comorbidities. In particular, more high-level evidence is required for older adults with Alzheimer's disease with epilepsy and status epilepticus. Future treatment studies should use greater homogeneity in the inclusion criteria to allow for clearer findings that can be comparable with other studies to build the existing treatment evidence base.

Comorbidities in newly diagnosed epilepsy: Pre-existing health conditions are common and complex across age groups

OBJECTIVES

People with epilepsy have a higher prevalence of medical and psychiatric comorbidities compared to the general population. Comorbidities are associated with poor epilepsy outcomes, and there have been recommendations for screening and early identification to improve clinical management. Data from 'First Seizure Clinics' (FSCs) with expert epileptological review can inform about disorders already present at the point of diagnosis of epilepsy or unprovoked seizures. Here, we aimed to describe pre-existing conditions with a focus on psychiatric, substance use, cardiac, neurological, and cancer health domains.

METHODS

We included 1383 adults who received a new diagnosis of epilepsy or unprovoked seizures at Austin Hospital (AH) or Royal Melbourne Hospital (RMH) (Australia) FSCs from 2000 to 2010. Data were audited from FSC records, primarily detailed interviews undertaken by epileptologists. Logistic regression examined age distribution and other risk factors.

RESULTS

The median age at FSC presentation was 37 years (IQR 26-53, range 18-94). Pre-existing conditions were reported by 40 %; from 32 % in the youngest group (18-30 years) to 53 % in the oldest (65+ years). Psychiatric (18 %) and substance use (16 %) disorders were most common, with higher prevalence among patients 18 to 65 years of age compared to those older than 65 years (p < 0.001). Cardiac, neurological, or cancer conditions were reported by 3-6 %, most often amongst those older than 65 years (p < 0.01). Eight percent (n = 112) reported disorders in >1 health domain. The commonest combination was a psychiatric condition with substance use disorder. Of the sixty-two patients reporting this combination, 61 were ≤65 years of age.

CONCLUSIONS

Pre-existing health conditions are present in a substantial proportion of patients diagnosed with epilepsy or unprovoked seizures. Disorders are highest amongst elders, but one-third of younger adults also reported positive histories. These are predominantly psychiatric and/or substance use disorders, conditions strongly associated with poor outcomes in the general population. These findings inform post-diagnosis planning and management, as well as research examining post-diagnostic outcomes and associations between comorbidities and epilepsy.

Exploring the association between epilepsy and depression: A systematic review and meta-analysis

OBJECTIVE

This study offers meta-analytic data on the potential association between epilepsy and depression especially for the prevalence of depression in epilepsy or vice versa.

METHODS

The relevant studies were searched and identified from nine electronic databases. Studies that mentioned the prevalence and/or incidence of epilepsy and depression were included. Hand searches were also included. The search language was English and the search time was through May 2022. Where feasible, random-effects models were used to generate pooled estimates.

RESULTS

After screening electronic databases and other resources, 48 studies from 6,234 citations were included in this meta-analysis. The period prevalence of epilepsy ranged from 1% to 6% in patients with depression. In population-based settings, the pooled period prevalence of depression in patients with epilepsy was 27% (95% CI, 23-31) and 34% in clinical settings (95% CI, 30-39). Twenty studies reported that seizure frequency, low income, unemployment of the patients, perception of stigma, anxiety, being female, unmarried status, disease course, worse quality of life, higher disability scores, and focal-impaired awareness seizures were risk factors for depression.

CONCLUSION

Our study found that epilepsy was associated with an increased risk of depression. Depression was associated with the severity of epilepsy.

Association between status epilepticus and cardiorespiratory comorbidity in patients with epilepsy: A population-based study

PURPOSE

This study aimed to evaluate the relationship between status epilepticus (SE) and cardiorespiratory comorbidity in patients with epilepsy.

METHODS

We conducted a population-based study using cloud-based aggregated electronic medical records from >53 million patients in the US (Explorys, IBM Watson; January 1999 to November 2020). During the study period, we identified patients with epilepsy with SE. Patients with a history of cardiac arrest, anoxic encephalopathy, and/or cerebrovascular disease were excluded. We reported the prevalences and prevalence ratios of cardiorespiratory and medical comorbidities using age- and sex-adjusted standardization.

RESULTS

We identified 494,790 patients with epilepsy and 19,190 had SE. Cardiovascular and respiratory diseases were statistically significantly more prevalent in patients with epilepsy with SE than in those without SE (adjusted prevalence ratio (APR) 1.13, prevalence 68.7% [95% confidence interval (CI): 67.6-69.9] vs 60.9% [95% CI: 60.7-61.1]) and (APR 1.25, 73.1% [95% CI: 71.8-74.3] vs 58.4% [95% CI: 58.1-58.6]), respectively. Aspiration pneumonia (APR 3.12, 0.47% [95% CI: 0.37-0.57] vs 0.15% [95% CI: 0.14-0.16]) and acute respiratory distress syndrome (APR 2.40, 0.47% [95% CI: 0.37-0.57] vs 0.20% [95% CI: 0.18-0.21]) were more prevalent in patients with epilepsy with SE. Common cardiovascular risk factors such as diabetes mellitus (APR 1.13, 17.1% [95% CI: 16.5-17.6] vs 15.1% [95% CI: 1.50-15.2]) and hypertension (APR 1.28, 10.6% [95% CI: 10.2-11.0] vs 8.31% [95% CI: 8.23-8.39]) were also more common in patients with epilepsy with SE.

CONCLUSION

In this population-based study, patients with epilepsy with SE had a statistically significantly higher prevalence of cardiorespiratory comorbidities than in those without SE.

Epidemiology and injectable antiseizure medication treatment patterns of seizure patients treated in United States hospitals

Objective

This study aimed to examine the epidemiology of seizures, clinical outcomes, and antiseizure medication treatment patterns among seizure patients treated in United States hospitals.

Design

A retrospective cross-sectional study was conducted using data from a large geographically diverse hospital discharge database.

Setting

860 acute care hospitals in the United States.

Participants

Patients aged ≥18 years with an outpatient emergency department or inpatient visit between 1 July 2016–31 December 2019 were included.

Intervention

None.

Main outcomes and measures

Key outcomes included prevalence of seizure, seizure type, admission point of origin, intensive care unit admission, discharge status, and injectable antiseizure medication utilization. Seizures were identified by the International Classification of Disease, Tenth Revision, Clinical Modification diagnosis codes.

Results

Among 36,598,627 unique emergency department outpatients (72,372,464 outpatient visits) and 16,543,592 unique inpatients (24,923,489 inpatient admissions) analyzed, seizure was present in 2.1% of outpatients (1.87% of outpatient visits) and 4.9% of inpatients (4.8% of inpatient admissions). In overall seizure patients, 49.1% were unclassified, 4.4% had generalized onset, 2.9% had focal onset, and 42.8% were categorized as other (including 38.5% with convulsion). Among seizure-associated inpatient admissions, <1% were transferred directly from skilled nursing facility or other long-term care facilities but 22.7% were discharged to such facilities. Nearly a third (31%) of all inpatients were admitted to ICU. About 88.3% of patients with injectable ASM use had monotherapy, 4.6% had polytherapy with 1 day or multiple non-consecutive days of overlap, and 7.0% had polytherapy with ≥2 consecutive days of overlap. The percentage of patients with no step down to any oral ASM ranged between 34.0–57.0%.

Conclusions

Seizures affect a substantial number of hospital-based emergency department outpatient and inpatient encounters and are associated with poor clinical outcomes and significant healthcare burden. Concomitant use of injectable ASMs is uncommon and a high percentage of IV ASM users with a diagnosis of seizure had no step down to oral therapy.

Relevance

The study findings may inform clinicians and hospital decision makers about current clinical practice and burden of seizures and identify areas to improve overall outcomes for patients with seizures.

Psychiatric comorbidities and all-cause mortality in epilepsy: A nationwide cohort study

Background

People with epilepsy (PWE) having comorbid psychiatric conditions may be at greater risk of death. We aimed to determine the association between psychiatric disorders and all-cause mortality among PWE after adjustment for somatic comorbidities.

Methods

Based on data from the National Health Insurance Fund, a Cox survival analysis was done within a retrospective open cohort of all PWE (≥12 years) in Lithuania between January 2014 and June 2020. Cox models comparing mortality between PWE with or without psychiatric comorbidities were adjusted for sex, age, hospitalizations, and the epilepsy-specific comorbidity index.

Results

Of 47,964 PWE (age Md = 49, IQR = 34–62 years, 60.3% male, follow-up Md = 4.4, IQR = 2.1–6.1 years), 10,290 (21.5%) died during the study. The diagnosis of any psychiatric disorder (n = 26,137, 54.5%) was associated with increased mortality when adjusted for only sex and age (HR = 1.13, 95% CI = 1.09 to 1.18). After including the epilepsy-specific comorbidity index, the number of hospitalizations and hospital days in the analysis, only self-harm (HR = 1.55, 95% CI = 1.40 to 1.71) and substance use disorders (HR = 1.39 95% CI = 1.32 to 1.47), but not any psychiatric comorbidities (HR = 0.92 95% CI = 0.88 to 0.96) were related to elevated all-cause mortality. Mood, anxiety and behavioral disorders were associated with lower odds of mortality; however, they were rarely documented.

Conclusions

Our results suggest that psychiatric comorbidities increase all-cause mortality among PWE through their association with coexisting somatic conditions as only substance use disorders and self-harm were independently related to elevated all-cause mortality. Future clinical interview-based studies should explore the relationship between mortality in epilepsy and psychiatric comorbidities while adjusting for somatic comorbidities.

Learning from the comorbidities of epilepsy

PURPOSE OF REVIEW

Comorbidities are a common feature in epilepsy, but neither the entire spectrum nor the significance of such comorbidities has been fully explored. We review comorbidities associated with epilepsy and their associated burden, provide an overview of relationships, and discuss a new conceptualization of the comorbidities.

RECENT FINDINGS

The epidemiology of the comorbidities of epilepsy and effects on health outcomes, healthcare use, and healthcare expenditures have been partly delineated. Distinct mechanisms of the associations have been suggested but not entirely ascertained. Movement from conceptualizing epilepsy as a condition to a symptom-complex has occurred.

SUMMARY

Comorbidities are common among people with epilepsy and are associated with poorer clinical outcomes and quality of life, greater use of health resources, and increased expenditure. Becoming aware of the associated mechanisms and their uncertainty is central to understanding the relationships between epilepsy and comorbid health conditions, which have implications for diagnosis and screening, medical management, and surgical management. Conceptualizing comorbidities of epilepsy as precipitating factors and epilepsy as the symptom will improve the understanding of epilepsy and catalyze research and improvements in clinical practice.

Association between antiseizure medications and quality of life in epilepsy: A mediation analysis

OBJECTIVE

The relationship between antiseizure medications (ASMs), which improve health outcomes by controlling seizures, and health-related quality of life (HRQOL) is poorly understood and may involve intermediate variables. We evaluated the potential mediators of the association between ASMs and HRQOL.

METHODS

Data are from an outpatient registry of adult patients with epilepsy seen at the Foothills Medical Center, Calgary, Alberta, Canada. Quality of life was measured using the 10-item Quality of Life in Epilepsy, and depression was measured using the Neurological Disorders Depression Inventory for Epilepsy. Propensity score matching was used to adjust for covariate imbalance between patients who received a single ASM (monotherapy) and those who received two or more ASMs (polytherapy) due to confounding. Mediation analysis was used to estimate the mediating effects of depression and ASM side effects on the association between patients' ASM polytherapy and HRQOL.

RESULTS

Of 778 patients included in this analysis, 274 (35.2%) were on two or more ASMs. Patient-reported depression and ASM side effects jointly mediated the association between ASMs and HRQOL; these mediators accounted for 42% of the total average effect of ASM polytherapy ( β  = -13.6, 95% confidence interval = -18.2 to -8.6) on HRQOL.

SIGNIFICANCE

These findings highlight the importance of managing depression and ASM side effects for improving health outcomes of patients requiring treatment with ASMs. Intervention programs aimed at improving HRQOL of patients with epilepsy need to target these potential mediators.

Clinical and Economic Outcomes of Intravenous Brivaracetam Compared With Levetiracetam for the Treatment of Seizures in United States Hospitals

Background: Seizures are common among hospitalized patients. Levetiracetam (LEV), a synaptic vesicle protein 2A (SV2A) ligand, is a common intravenous (IV) anti-seizure medication option in hospitals. Brivaracetam (BRV), a selective SV2A ligand for treatment of focal seizures in patients ≥16 years, has greater binding affinity, higher lipophilicity, and faster brain entry than IV LEV. Differences in clinical outcomes and associated costs between IV BRV and IV LEV in treating hospitalized patients with seizure remain unknown.

Objectives: To compare the clinical outcomes, costs, and healthcare resource utilization between patients with seizure treated with IV BRV and those with IV LEV within hospital setting.

Design/Methods: A retrospective cohort analysis was performed using chargemaster data from 210 United States hospitals in Premier Healthcare Database. Adult patients (age ≥18 years) treated intravenously with LEV or BRV (with or without BZD) and a seizure discharge diagnosis between July 1, 2016 and December 31, 2019 were included. The cohorts were propensity score-matched 4:1 on baseline characteristics. Outcomes included intubation rates, intensive care unit (ICU) admission, length of stay (LOS), all-cause and seizure-related readmission, total hospitalization cost, and in-hospital mortality. A multivariable regression analysis was performed to determine the association between treatment and main outcomes adjusting for unbalanced confounders.

Results: A total of 450 patients were analyzed (IV LEV, n = 360 vs. IV BRV, n = 90). Patients treated with IV BRV had lower crude prevalence of ICU admission (14.4 vs. 24.2%, P < 0.05), 30-day all-cause readmission (1.1 vs. 6.4%, P = 0.06), seizure-related 30-day readmission (0 vs. 4.2%, P < 0.05), similar mean total hospitalization costs ($13,715 vs. $13,419, P = 0.91), intubation (0 vs. 1.1%, P = 0.59), and in-hospital mortality (4.4 vs. 3.9%, P = 0.77). The adjusted odds for ICU admission (adjusted odds ratio [_aOR] = 0.6; 95% confidence interval [CI]:0.31, 1.16; P = 0.13), 30-day all-cause readmission (_aOR = 0.17; 95% CI:0.02, 1.24; P = 0.08), and in-hospital mortality (_aOR = 1.15; 95% CI:0.37, 3.58, P = 0.81) were statistically similar between comparison groups.

Conclusion: The use of IV BRV may provide an alternative to IV LEV for management of seizures in hospital setting due to lower or comparable prevalence of ICU admission, intubation, and 30-day seizure-related readmission. Additional studies with greater statistical power are needed to confirm these findings.

Mortality among People with Epilepsy: A Retrospective Nationwide Analysis from 2016 to 2019

We estimated age-adjusted mortality and investigated the dominant causes of death as well as comorbidities among people with epilepsy (PWE) in Lithuania, a country with frequent deaths from external causes. From 2016 to 2019, the age-adjusted rate of death among PWE in Lithuania was compared with mortality data in the general population. Each year of analysis, individuals who were diagnosed with epilepsy comprised a retrospective cohort. The standardized mortality ratio (SMR) of PWE varied from 2.93 (95% CI 2.78 to 3.07) to 3.18 (95% CI 3.02 to 3.34). PWE died at least one decade earlier than expected in the general population. The dominant causes of death were cardiovascular diseases (their proportion ranged from 44.8% to 49.3%), cancer (16.7% to 21.3%) and external causes of death (8.5% to 10.9%). The proportion of the latter decreased over time (r = −0.99, p = 0.01), whereas the SMR for external causes of death remained relatively constant. Epilepsy was the underlying cause of death in 163 cases (2.6%), and noted as a condition contributing to death in 1010 cases (15.9%). Cerebrovascular and cardiological conditions and dementia were the most frequent comorbidities among PWE before their death. Epilepsy-unrelated causes of death are relevant contributors to mortality among PWE. There is a need for PWE-oriented societal interventions to reduce the frequency of external deaths beyond the trend in the general population.

Quality of Life in Epilepsy: Same questions, but different meaning to different people

OBJECTIVES

Patient-reported outcome measures (PROMs) are used widely to elicit patient's self-appraisal of their health status and quality of life. One fundamental assumption when measuring PROMs is that all individuals interpret questions about their health status in a consistent manner. However, subgroups of patients with a similar health condition may respond differently to PROM questions (ie, differential item functioning [DIF]), leading to biased estimates of group differences on PROM scores. Understanding these differences can help inform the clinical interpretation of PROMs. This study examined whether DIF affects 10-item Quality of Life in Epilepsy (QOLIE10) scores reported by patients with epilepsy in outpatient clinics.

METHODS

Data were from the Calgary Comprehensive Epilepsy Program, a prospective registry of patients with epilepsy in Calgary, Alberta. Latent variable mixture models (LVMMs) based on standard two-parameter graded response models with increasing numbers of latent classes were applied to QOLIE10 item data. Model fit was assessed using the Bayesian Information Criterion (BIC) and latent class model entropy. Ordinal logistic regression was used to identify QOLIE10 items that exhibited DIF.

RESULTS

In this cohort of 1143 patients, 567 (49.6%) were female and the median age was 37.0 (interquartile range [IQR] 27.0) years. A two-class LVMM, which provided the best fit to the data, identified two subgroups of patients with different response patterns to QOLIE10 items, with class proportions of 0.62 and 0.38. The two subgroups differed with respect to antiseizure polytherapy, reported medication side effects, frequency of seizures, and psychiatric comorbidities. QOLIE10 items on the physical and psychological side effects of medication exhibited large DIF effects.

SIGNIFICANCE

Our study revealed two different response patterns to quality-of-life instruments, suggesting heterogeneity in how patients interpret some of the questions. Researchers and users of PROMs in epilepsy need to consider the differential interpretation of items for various instruments to ensure valid understanding and comparisons of PROM scores.

Classifying epilepsy pragmatically: Past, present, and future

The classification of epilepsy is essential for people with epilepsy and their families, healthcare providers, physicians and researchers. The International League Against Epilepsy proposed updated seizure and epilepsy classifications in 2017, while another four-dimensional epilepsy classification was updated in 2019. An Integrated Epilepsy Classification system was proposed in 2020. Existing classifications, however, lack consideration of important pragmatic factors relevant to the day-to-day life of people with epilepsy and stakeholders. Despite promising developments, consideration of comorbidities in brain development, genetic causes, and environmental triggers of epilepsy remains largely user-dependent in existing classifications. Demographics of epilepsy have changed over time, while existing classification schemes exhibit caveats. A pragmatic classification scheme should incorporate these factors to provide a nuanced classification. Validation across disparate contexts will ensure widespread applicability and ease of use. A team-based approach may simplify communication between healthcare personnel, while an individual-centred perspective may empower people with epilepsy. Together, incorporating these elements into a modern but pragmatic classification scheme may ensure optimal care for people with epilepsy by emphasising cohesiveness among its myriad users. Technological advancements such as 7T MRI, next-generation sequencing, and artificial intelligence may affect future classification efforts.

Clinical characteristics of epilepsy in resource-limited communities in Punjab, Northwest India

OBJECTIVES

To describe clinical characteristics of a community-based epilepsy cohort from resource-limited communities in Punjab, Northwest India.

METHODS

The cohort was gathered following a two-stage screening survey. We cross-sectionally examined and followed up the cohort for one year. A panel of neurologists assigned seizure types, syndromes, and putative etiologies and categorized drug responsiveness.

RESULTS

The cohort of 240 included 161 (67.1%) men, 109 (45.4%) illiterates and 149 (62.1%) unemployed. Current age was >18 years in 155 (64.6%) but age at epilepsy onset was <18 years in 173 (72.1%). Epilepsies due to structural and metabolic causes were diagnosed in 99 (41.3%), but syndromic assignments were not possible in 97 (40.4%). After one year, drug-resistant epilepsy was established in 74 (30.8%). Perinatal events (n = 35; 14.6%) followed by CNS infections (n = 32; 13.3%) and traumatic brain injury (n = 12; 5.0%) were common risk factors. Most of those with CNS infections (n = 19; 63.3%), perinatal antecedents (n = 23; 76.7%), and other acquired risk factors (n = 27; 90.0%) presented with epilepsy due to structural and metabolic causes. Perinatal events were the putative etiology for nearly 40.7% of generalized epilepsies due to structural and metabolic causes and 28.2% of all epilepsies with onset <10 years.

SIGNIFICANCE

Existing classifications schemes should be better suited to field conditions in resource-limited communities in low- and middle-income countries. The finding of drug-resistant epilepsy in nearly at least a third in a community-based sample underscores an unmet need for enhancing services for this segment within healthcare systems. Perinatal events, CNS infections, and head injury account for a third of all epilepsies and hence preventative interventions focusing on these epilepsy risk factors should be stepped up.

Association of Levels of Specialized Care With Risk of Premature Mortality in Patients With Epilepsy

Importance

Patients with epilepsy are at an elevated risk of premature mortality. Interventions to reduce this risk are crucial.

Objective

To determine if the level of care (non-neurologist, neurologist, or comprehensive epilepsy program) is negatively associated with the risk of premature mortality.

Design, Setting, and Participants

In this retrospective open cohort study, all adult patients 18 years or older who met the administrative case definition for incident epilepsy in linked databases (Alberta Health Services administrative health data and the Comprehensive Calgary Epilepsy Programme Registry [CEP]) inclusive of the years 2002 to 2016 were followed up until death or loss to follow-up. The final analyses were performed on May 1, 2019.

Exposures

Evaluation by a non-neurologist, neurologist, or epileptologist.

Main Outcomes and Measures

The outcome was all-cause mortality. We used extended Cox models treating exposure to a neurologist or the CEP as time-varying covariates. Age, sex, socioeconomic deprivation, disease severity, and comorbid burden at index date were modeled as fixed-time coefficients.

Results

A total 23 653 incident cases were identified (annual incidence of 89 per 100 000); the mean age (SD) at index date was 50.8 (19.1) years and 12 158 (50.3%) were women. A total of 14 099 (60%) were not exposed to specialist neurological care, 9554 (40%) received care by a neurologist, and 2054 (9%) received care in the CEP. In total, 4098 deaths (71%) occurred in the nonspecialist setting, 1481 (26%) for those seen by a neurologist, and 176 (3%) for those receiving CEP care. The standardized mortality rate was 7.2% for the entire cohort, 9.4% for those receiving nonspecialist care, 5.6% for those seen by a neurologist, and 2.8% for those seen in the CEP. The hazard ratio (HR) of mortality was lower in those receiving neurologist (HR, 0.85; 95% CI, 0.77-0.93) and CEP (HR, 0.49; 95% CI, 0.38-0.62) care. In multivariable modeling, specialist care, the age at index, and disease severity were retained in the final model of the association between specialist care and mortality.

Conclusions and Relevance

Exposure to specialist care is associated with incremental reductions in the hazard of premature mortality. Those referred to a comprehensive epilepsy program received the greatest benefit.

Psychosocial profiles and their predictors in epilepsy using patient-reported outcomes and machine learning

OBJECTIVE

To apply unsupervised machine learning to patient-reported outcomes to identify clusters of epilepsy patients exhibiting unique psychosocial characteristics.

METHODS

Consecutive outpatients seen at the Calgary Comprehensive Epilepsy Program outpatient clinics with complete patient-reported outcome measures on quality of life, health state valuation, depression, and epilepsy severity and disability were studied. Data were acquired at each patient's first clinic visit. We used k-means++ to segregate the population into three unique clusters. We then used multinomial regression to determine factors that were statistically associated with patient assignment to each cluster.

RESULTS

We identified 462 consecutive patients with complete patient-reported outcome measure (PROM) data. Post hoc analysis of each cluster revealed one reporting elevated measures of psychosocial health on all five PROMs ("high psychosocial health" cluster), one with intermediate measures ("intermediate" cluster), and one with poor overall measures of psychosocial health ("poor psychosocial health" cluster). Failing to achieve at least 1 year of seizure freedom (relative risk [RR] = 4.34, 95% confidence interval [CI] = 2.13-9.09) predicted placement in the "intermediate" cluster relative to the "high" cluster. In addition, failing to achieve seizure freedom, social determinants of health, including the need for partially or completely subsidized income support (RR = 6.10, 95% CI = 2.79-13.31, P < .001) and inability to drive (RR = 4.03, 95% CI = 1.6-10.00, P = .003), and a history of a psychiatric disorder (RR = 3.16, 95% CI = 1.46-6.85, P = .003) were associated with the "poor" cluster relative to the "high" cluster.

SIGNIFICANCE

Seizure-related factors appear to drive placement in the "intermediate" cluster, with social determinants driving placement in the "poor" cluster, suggesting a threshold effect. Precision intervention based on cluster assignment, with an initial emphasis on improving social support and careful titration of medications for those reporting the worst psychosocial health, could help optimize health for patients with epilepsy.

Healthcare resource utilization and costs before and after lacosamide initiation as adjunctive therapy among patients with epilepsy in the United States

OBJECTIVE

The objective of this study was to evaluate all-cause and epilepsy-specific healthcare resource utilization and costs following lacosamide (LCM) initiation as adjunctive therapy for the treatment of epilepsy.

METHODS

A noninterventional retrospective database analysis was conducted that examined patients diagnosed as having epilepsy who added LCM to existing antiepileptic drug (AED) therapy between 2009 and 2016 (the first LCM prescription was the index event). This study used a single-case design whereby patients served as their own controls. Patients were further required to have a minimum of 12 months of continuous eligibility before (preindex period) and after (postindex period) their index event. In the 12-month postindex period, the only allowed AED regimen change was the addition of LCM. Demographic and clinical characteristics were measured at index and during the preindex period, respectively. All-cause and epilepsy-specific healthcare resource utilization and costs were measured and compared in the pre- and postindex periods. Paired t- and McNemar's tests were conducted to assess the significant differences between pre- and postindex. Univariate analyses were used to analyze the impact of LCM on specific subpopulations.

RESULTS

The study sample comprised of 2171 patients: mean (standard deviation [SD]) age: 38.9 (19.3) years; 52.6% female. Just over half (56%) of these patients were on monotherapy before adding LCM. Prior to adding LCM, 28.8% of patients had an epilepsy-specific inpatient (IP) admission, and 35.7% of patients had an all-cause IP admission, compared with 18.2% and 26.1% of patients in the post-LCM period, respectively (both p < 0.0001). Likewise, 35.6% of patients had an epilepsy-specific emergency room (ER) visit, and 50.0% had an all-cause ER visit prior to adding LCM, compared with 23.8% and 42.1% in post-LCM, respectively (both p < 0.0001). After adding LCM, one-year mean [SD] epilepsy-specific IP admission costs decreased by 42.9% ($13,647 [$52,290] to $7788 [$32,321]), and all-cause IP admission costs decreased by 38.6% ($20,654 [$72,716] to $12,688 [$46,120]) (both p < 0.0001). One-year epilepsy-specific mean [SD] ER costs decreased by 35.2% ($691 [$1756] to $448 [$1909]; p < 0.0001), and all-cause ER cost decreased by 17.8% ($1217 [$3014] to $1000 [$2970]; p < 0.01).

CONCLUSIONS

Epilepsy-related IP hospitalizations and ER visits (indicators of seizures) were significantly reduced in patients with epilepsy 12 months after adding LCM as an adjunctive therapy to existing AED treatment in a real-world setting, leading to reduced healthcare resource utilization and epilepsy costs.

Cannabis use is both independently associated with and mediates worse psychosocial health in patients with epilepsy

OBJECTIVE

To examine whether cannabis use is associated with or mediates psychosocial health in people with epilepsy.

METHODS

Consecutive adult epilepsy patients visiting the Calgary Comprehensive Epilepsy Programme clinic were administered validated patient-reported outcome measures (PROMs) including the Neurological Disorders Depression Inventory for Epilepsy (NDDI-E), Quality of Life in Epilepsy (QOLIE-10-P), EuroQOL five dimensions five level scale (EQ-5D-5L), Global Assessment of Severity of Epilepsy Scale, Global Assessment of Disability Associated with Seizures Scale and the Treatment Satisfaction Questionnaire for Medication scale. We used multiple regression analyses to investigate associations between cannabis use and PROMs. Mediation analyses were performed to determine the degree to which cannabis modulated the associations between current or past psychiatric disorders, monthly seizure frequency, and 1-year seizure freedom on psychosocial health.

RESULTS

Of 337 consecutive patients, 71 (21%) reported cannabis use. Cannabis use was independently associated with depression (NDDI-E score≥14; OR 3.90; 95% CI 2.01 to 7.59; p<0.001), lower quality of life (β=-16.73, 95% CI - 26.26 to - 7.20; p=0.001), worse epilepsy-related disability (OR 2.23, 95% CI 1.19 to 4.17; p=0.01) and lower satisfaction with antiepileptic medication (OR 0.41, 95% CI 0.23 to 0.72; p=0.002). Cannabis use mediates 7%-12% of the effect of a psychiatric history on depression, worse quality of life and worse health valuation.

CONCLUSIONS

There is a strong and independent association between cannabis use and poor psychosocial health, and it partially mediates the deleterious effect of a psychiatric history on these same outcomes. Inclusion of PROMs in future cannabis trials is warranted.

Premature mortality in persons with epilepsy and schizophrenia: A population-based nationwide cohort study

OBJECTIVE

To determine the mortality for persons with epilepsy and schizophrenia by absolute and relative measures.

METHODS

This is a population-based nationwide cohort study of persons born in Denmark from 1960 to 1987 who were alive and residing in Denmark on their 25th birthday. We identified persons diagnosed with epilepsy and schizophrenia prior to their 25th birthday and followed them to death, emigration, or December 31, 2012, whichever came first. The primary outcome was overall mortality. Data were analyzed using Cox regressions.

RESULTS

Persons were followed for 24 167 573 person years; the median was 15 years. The mortality rate ratio was 4.4 (95% confidence interval [CI] = 4.1-4.7) for persons with epilepsy, 6.6 (95% CI = 6.1-7.1) for persons with schizophrenia, and 12.8 (95% CI = 9.1-18.1) for persons with both disorders, compared with persons without these disorders. The estimated cumulative mortality at the age of 50 years was 3.1% (95% CI = 3.0-3.1) for persons without epilepsy and schizophrenia, 10.7% (95% CI = 9.7-11.8) for persons with epilepsy, 17.4% (95% CI = 16.0-18.8) for persons with schizophrenia, and 27.2% (95% CI = 15.7-40.1) for persons with both disorders.

SIGNIFICANCE

Persons with epilepsy and schizophrenia have very high mortality; more than one in four persons with both disorders died between the age of 25 and 50 years, indicating that these patients need special clinical attention.

Depression as a risk factor for the development of rheumatoid arthritis: a population-based cohort study

Objectives

Major depressive disorder (MDD) is associated with increased levels of systemic proinflammatory cytokines, including tumour necrosis factor alpha. As these cytokines are pathogenic in autoimmune diseases such as rheumatoid arthritis (RA), our aim was to explore on a population-level whether MDD increases the risk of developing RA.

Methods

A retrospective cohort study was conducted using The Health Improvement Network (THIN) database (from 1986 to 2012). Observation time was recorded for both the MDD and referent cohorts until patients developed RA or were censored. Cox proportional hazards models were used to determine the risk of developing RA among patients with MDD, accounting for age, sex, medical comorbidities, smoking, body mass index and antidepressant use.

Results

A cohort of 403 932 patients with MDD and a referent cohort of 5 339 399 patients without MDD were identified in THIN. Cox proportional hazards models revealed a 31% increased risk of developing RA among those with MDD in an unadjusted model (HR=1.31, 95% CI 1.25 to 1.36, p<0.0001). When adjusting for all covariates, the risk remained significantly increased among those with MDD (HR=1.38, 95% CI 1.31 to 1.46, p<0.0001). Antidepressant use demonstrated a confounding effect that was protective on the association between MDD and RA.

Conclusion

MDD increased the risk of developing RA by 38%, and antidepressants may decrease this risk in these patients. Future research is necessary to confirm the underlying mechanism of MDD on the pathogenesis of RA.

Risk assessment of in-hospital mortality of patients with epilepsy: A large cohort study

PURPOSE

This study aimed to explore the mortality risks of hospitalized patients with epilepsy (PWE).

METHODS

Our data source was extracted from discharge abstracts in a hospital medical database. Various clinical variables, including demographical characteristics, natural features of epilepsy, and comprehensive set of comorbidities, were screened to investigate the risk. Comorbidities were defined using a validated ICD-10-based classification. The distributions of comorbid conditions and demographics were presented. In-hospital mortality rates of groups with epilepsy and without epilepsy were compared. Logistic regression was applied to explore the important predictors of in-hospital mortality.

RESULTS

A cohort of 11,422 PWE (male: 58.5%, mean age: 40.2 years) was recruited for the study. The most common comorbidities were cerebrovascular disease, hypertension, and peripheral vascular disease, which accounted for 23.5%, 18.8%, and 8.0% of the study cohort, respectively. In-hospital mortality rates were 2.9% and 1.1% in the epilepsy and nonepilepsy cohort, respectively. Male patients exhibited an increased risk of death (odds ratio (OR) = 1.2; 95% confidence interval (CI) = 1.0-1.6). Patients aged over 65 years were more likely to die than those below 18 years (OR = 18.2; 95% CI = 8.8-31.0). Patients with comorbidities, including central nervous system (CNS) infections, renal disease, traumatic brain and head injuries, anoxic brain injury, metastatic cancer, pulmonary circulation disorders, encephalopathy, solid tumor without metastasis, cardiac arrhythmias, and diabetes without complication, had a higher risk of in-hospital death than patients without comorbidities (OR = 6.1, 5.2, 5.1, 4.4, 3.7, 2.5, 2.4, 2.0, 1.5, 1.4, respectively; 95% CI = 4.1-9.1, 3.8-7.0, 2.8-9.5, 2.4-8.3, 2.2-6.3, 1.5-4.3, 1.4-4.2, 1.1-3.7, 1.1-2.1, 1.0-1.9, respectively).

CONCLUSION

The in-hospital mortality of PWE increased remarkably with age, and this parameter was predominant in male patients. Central nervous system infection, renal disease, traumatic brain and head injuries, anoxic brain injury, metastatic cancer, pulmonary circulation disorders, encephalopathy, solid tumor without metastasis, cardiac arrhythmias, and diabetes without complication were the most important comorbidities associated with in-hospital death.

Mortality-specific comorbidity among inpatients with epilepsy: A preliminary cross-sectional study in West China

PURPOSE

The purpose of this study was to investigate the current condition of mortality-specific comorbidity among hospitalized patients with epilepsy (PWE).

METHODS

The discharge abstract records of PWE from over 730,000 admissions were extracted from the hospital medical database. Fourteen mortality-related comorbidities from an epilepsy-specific index (ESI) were selected for the present assessment. The hospital-based prevalence of these comorbidities was estimated. The distributions of PWE with an ESI-based prognostic score were calculated.

RESULTS

A cohort of 11,422 PWE (male 58.5%) was included in the present study. The order of comorbidities in terms of high to low prevalence ranking was as follows: hypertension (19.6%), peripheral vascular disease (8.1%), cardiac arrhythmias (5.8%), dementia (4.6%), renal disease (4.1%), congestive heart failure (3.8%), metastatic cancer (3.4%), brain tumor (2.4%), paraplegia and hemiplegia (2.0%), solid tumor without metastasis (1.7%), anoxic brain injury (1.4%), pulmonary circulation disorders (1.3%), moderate or severe liver disease (1.1%), and aspiration pneumonia (0.2%). High rates of comorbidities in the elderly were also noted. Spearman correlation analysis showed a moderate correlation between the changes in ages and prognostic score with a rho of 0.6 (p<0.001). The percentage of females with a score of 0 was higher than that of males (p<0.001), indicating that the prognostic survival of the majority of females was relatively longer than that of males.

CONCLUSION

Our study demonstrated that the comorbidity burden of female PWE was relatively lower than that of male PWE. High prevalence of cardiac and vascular diseases was found in PWE, thereby affecting the long-term survival rate. Considering that the propensity of increased comorbidity was prevalent with age, we should implement early preventive measures to manage the potential comorbidities associated with mortality, reduce disease burden, and prolong the survival of PWE.

Electroconvulsive therapy and subsequent epilepsy in patients with affective disorders: A register-based Danish cohort study

OBJECTIVE

It has been suggested that Electroconvulsive Therapy (ECT) might increase the risk of epilepsy but the few patient studies with retrospective data from medical records do not support the hypothesis. The aim of this study was to examine the relationship between ECT and subsequent incident epilepsy in patients with affective disorder. We also explored whether any association varied with number of ECTs and time since last treatment.

METHODS

All 169,457 patients with first hospital contact for an affective disorder between January 2005 and December 2015 were identified in the Danish National Patient Registry and followed for incident epilepsy from January 2005 until November 2016. The association between ECT and epilepsy was examined using Cox proportional hazard regression with adjustment for gender, age, educational level, comorbid schizophrenia, previous stroke and antidepressant and antipsychotic medication use.

RESULTS

A total of 5875 patients had at least one ECT and 1873 patients developed epilepsy (Incidence rate: 213 pr. 100,000 person years) during the follow-up of mean 5 years. In patients below age 40 years, ECT was associated with a higher rate of epilepsy after adjustment for covariables (Hazard Ratio (HR) = 1.84; 95% Confidence Intervals (CI) = [1.24-2.74]). In patients aged 41-60 years ECT was not associated with epilepsy, while for those above 60 treated with ECT the rate was lower (HR = 0.57; (95% CI = [0.37-0.89]).

CONCLUSION

In patients with affective disorders, we found a weak positive association between ECT and subsequent diagnosis of epilepsy in those younger than 40 years, and a weak negative association in patients older than 60 years. The associations might be subject to residual confounding from risk factors related to ECT.

Health care cost associated with the use of enzyme-inducing and non-enzyme-active antiepileptic drugs in the UK: a long-term retrospective matched cohort study

Background

Some antiepileptic drugs (AEDs) induce expression of hepatic enzymes. This can contribute to comorbidities via interference with metabolic pathways and concomitant drug metabolization, thereby increasing the likelihood of health care interventions. Using medical records, we compared the direct health care cost in patients initiating epilepsy therapy with enzyme-inducing AEDs (EIAEDs) vs non-enzyme-active AEDs (nEAAEDs) over up to 12 years.

Methods

Patients with untreated epilepsy were indexed in the UK Clinical Practice Research Datalink and Hospital Episode Statistics database when prescribed a new EIAED or nEAAED between January 2001 and December 2010. Propensity score matching reduced confounding factors between cohorts. Patients were followed until cohort treatment failure or data cut-off. The primary outcome was the median standardized monthly direct health care cost during follow-up in 2014 £GBP, calculated using published reference costs and compared using a Mann–Whitney U test.

Results

The unmatched EIAED cohort (n = 2752) was older (54 vs 46 years), more likely to be male, had more comorbidities, and higher health care resource use/cost during the 1-year pre-index period (median £3014 vs £2516) than the nEAAED cohort (n = 2,137). The most common index EIAED and nEAAED were carbamazepine (63.3%) and lamotrigine (58.0%), respectively. After matching, cohorts had similar features (n = 951 each). Over up to 12 years of follow-up, the median standardized monthly direct health care cost was £229 for the EIAED and £188 for the nEAAED cohorts (p = 0.0091). The median cost was higher for the EIAED cohort in every year of follow-up. In the two cohorts, 25.1% and 20.1% of total mean cost during follow-up was epilepsy-related, with approximately 4.6% and 3.0% for AED acquisition, respectively. The median time to cohort treatment failure was shorter in the matched EIAED cohort (468 vs 1194 days).

Conclusions

Patients in the UK who initiated epilepsy therapy with an EIAED appeared to be at higher risk of complications associated with enzyme induction. In long-term matched cohort analyses, the median total direct health care cost associated with EIAED therapy was higher than with nEAAEDs. Changing current treatment practices could potentially improve patient outcomes and reduce costs.

Electronic supplementary material

The online version of this article (doi:10.1186/s12883-017-0837-y) contains supplementary material, which is available to authorized users.

The heart of epilepsy: Current views and future concepts

Cardiovascular (CV) comorbidities are common in people with epilepsy. Several mechanisms explain why these conditions tend to co-exist including causal associations, shared risk factors and those resulting from epilepsy or its treatment. Various arrhythmias occurring during and after seizures have been described. Ictal asystole is the most common cause. The converse phenomenon, arrhythmias causing seizures, appears extremely rare and has only been reported in children following cardioinihibitory syncope. Arrhythmias in epilepsy may not only result from seizure activity but also from a shared genetic susceptibility. Various cardiac and epilepsy genes could be implicated but firm evidence is still lacking. Several antiepileptic drugs (AEDs) triggering conduction abnormalities can also explain the co-existence of arrhythmias in epilepsy. Epidemiological studies have consistently shown that people with epilepsy have a higher prevalence of structural cardiac disease and a poorer CV risk profile than those without epilepsy. Shared CV risk factors, genetics and etiological factors can account for a significant part of the relationship between epilepsy and structural cardiac disease. Seizure activity may cause transient myocardial ischaemia and the Takotsubo syndrome. Additionally, certain AEDs may themselves negatively affect CV risk profile in epilepsy. Here we discuss the fascinating borderland of epilepsy and cardiovascular conditions. The review focuses on epidemiology, clinical presentations and possible mechanisms for shared pathophysiology. It concludes with a discussion of future developments and a call for validated screening instruments and guidelines aiding the early identification and treatment of CV comorbidity in epilepsy.

Outcome of seizures in the general population after 25 years: a prospective follow-up, observational cohort study

OBJECTIVES

We investigated long-term (to 25 years) seizure prognosis and survival in people with newly diagnosed epilepsy in the community. We explored whether prognosis is different in those with epilepsy (>2 unprovoked seizures) and those with a single seizure at presentation.

METHODS

This is a prospective observational cohort study of people with newly diagnosed seizures. We investigated seizure outcome and survival in people presenting with a single seizure and in those presenting with >2 seizures (epilepsy).

RESULTS

695 people (median follow-up 23.6 years) had unprovoked epileptic seizures. For seizure analysis we excluded 38 people with missing data leaving 657 (309 male, and 249 aged <18 years). Seizures recurred in 67%. The 354 people with epilepsy were only slightly more likely to have further seizure recurrence than the 302 people with a single seizure at presentation (HR 1.32, 95% CI 1.09 to 1.59). In 327 people with complete follow-up, 268 (82%, 95% CI 77% to 86%) were in terminal remission; (80%, (95% CI 73% to 85%) in those with epilepsy at presentation). Premature mortality was increased in people with epilepsy (standardised mortality ratio 1.67; 95% CI 1.40 to 1.99) and those with a single seizure at presentation (standardised mortality ratio 2.65; 95% CI 2.23 to 3.15). It is also high in those with early remission.

CONCLUSIONS

People with epilepsy and with single seizures at presentation in the community generally have good prognosis for seizure control with prolonged follow-up. The risk of premature mortality is significantly increased in both groups.

Long-term reduction of health care costs and utilization after epilepsy surgery

OBJECTIVE

To assess long-term direct medical costs, health care utilization, and mortality following resective surgery in persons with uncontrolled epilepsy.

METHODS

Retrospective longitudinal cohort study of Medicaid beneficiaries with epilepsy from 2000 to 2008. The study population included 7,835 persons with uncontrolled focal epilepsy ages 18-64 years, with an average follow-up time of 5 years. Of these, 135 received surgery during the study period. To account for selection bias, we used risk-set optimal pairwise matching on a time-varying propensity score, and inverse probability of treatment weighting. Repeated measures generalized linear models were used to model utilization and cost outcomes. Cox proportional hazard was used to model survival.

RESULTS

The mean direct medical cost difference between the surgical group and control group was $6,806 after risk-set matching. The incidence rate ratio of inpatient, emergency room, and outpatient utilization was lower among the surgical group in both unadjusted and adjusted analyses. There was no significant difference in mortality after adjustment. Among surgical cases, mean annual costs per subject were on average $6,484 lower, and all utilization measures were lower after surgery compared to before.

SIGNIFICANCE

Subjects that underwent epilepsy surgery had lower direct medical care costs and health care utilization. These findings support that epilepsy surgery yields substantial health care cost savings.

Predicting frequent ED use by people with epilepsy with health information exchange data

OBJECTIVES

To describe (1) the predictability of frequent emergency department (ED) use (a marker of inadequate disease control and/or poor access to care), and (2) the demographics, comorbidities, and use of health services of frequent ED users, among people with epilepsy.

METHODS

We obtained demographics, comorbidities, and 2 years of encounter data for 8,041 people with epilepsy from a health information exchange in New York City. Using a retrospective cohort design, we explored bivariate relationships between baseline characteristics (year 1) and subsequent frequent ED use (year 2). We then built, evaluated, and compared predictive models to identify frequent ED users (≥4 visits year 2), using multiple techniques (logistic regression, lasso, elastic net, CART [classification and regression trees], Random Forests, AdaBoost, support vector machines). We selected a final model based on performance and simplicity.

RESULTS

People with epilepsy who, in year 1, were adults (rather than children or seniors), male, Manhattan residents, frequent users of health services, users of multiple health systems, or had medical, neurologic, or psychiatric comorbidities, were more likely to frequently use the ED in year 2. Predictive techniques identified frequent ED visitors with good positive predictive value (approximately 70%) but poor sensitivity (approximately 20%). A simple strategy, selecting individuals with 11+ ED visits in year 1, performed as well as more sophisticated models.

CONCLUSIONS

People with epilepsy with 11+ ED visits in a year are at highest risk of continued frequent ED use and may benefit from targeted intervention to avoid preventable ED visits. Future work should focus on improving the sensitivity of predictions.

Administrative data linkage to evaluate a quality improvement program in acute stroke care, Georgia, 2006-2009

Introduction

Tracking the vital status of stroke patients through death data is one approach to assessing the impact of quality improvement in stroke care. We assessed the feasibility of linking Georgia hospital discharge data with mortality data to evaluate the effect of participation in the Georgia Coverdell Acute Stroke Registry on survival rates among acute ischemic stroke patients.

Methods

Multistage probabilistic matching, using a fine-grained record integration and linkage software program and combinations of key variables, was used to link Georgia hospital discharge data for 2005 through 2009 with mortality data for 2006 through 2010. Data from patients admitted with principal diagnoses of acute ischemic stroke were analyzed by using the extended Cox proportional hazard model. The survival times of patients cared for by hospitals participating in the stroke registry and of those treated at nonparticipating hospitals were compared.

Results

Average age of the 50,579 patients analyzed was 69 years, and 56% of patients were treated in Georgia Coverdell Acute Stroke Registry hospitals. Thirty-day and 365-day mortality after first admission for stroke were 8.1% and 18.5%, respectively. Patients treated at nonparticipating facilities had a hazard ratio for death of 1.14 (95% confidence interval, 1.03–1.26; P = .01) after the first week of admission compared with patients cared for by hospitals participating in the registry.

Conclusion

Hospital discharge data can be linked with death data to assess the impact of clinical-level or community-level chronic disease control initiatives. Hospitals need to undertake quality improvement activities for a better patient outcome.

Hospital crossover increases utilization for people with epilepsy: a retrospective cohort study

OBJECTIVES

"Hospital crossover" occurs when people visit multiple hospitals for care, which may cause gaps in electronic health records. Although crossover is common among people with epilepsy, the effect on subsequent use of health services is unknown. Understanding this effect will help prioritize health care delivery innovations targeted for this population.

METHODS

We collected de-identified information from a health information exchange network describing 7,836 people with epilepsy who visited any of seven hospitals in New York, NY from 2009-2012. Data included demographics, comorbidities, and 2 years of visit information from ambulatory, inpatient, emergency department (ED), and radiology settings. We performed two complementary retrospective cohort analyses, in order to (1) illustrate the effect on a carefully selected subgroup, and (2) confirm the effect across the study population. First, we performed a matched cohort analysis on 410 pairs of individuals with and without hospital crossover in the baseline year. Second, we performed a propensity score odds weighted ordinal logistic regression analysis to estimate the effect across all 7,836 individuals. The outcomes were the use of six health services in the follow-up year.

RESULTS

In the matched pair analysis, baseline hospital crossover increased the odds of more visits in the ED (odds ratio 1.42, 95% confidence interval [CI] 1.05-1.95) and radiology settings (1.7, 1.22-2.38). The regression analysis confirmed the ED and radiology findings, and also suggested that crossover led to more inpatient admissions (1.35, 1.11-1.63), head CTs (1.44, 1.04-2), and brain MRIs (2.32, 1.59-3.37).

SIGNIFICANCE

Baseline hospital crossover is an independent marker for subsequent increased health service use in multiple settings among people with epilepsy. Health care delivery innovations targeted for people with epilepsy who engage in hospital crossover should prioritize (1) sharing radiology images and reports (to reduce unnecessary radiology use, particularly head CTs), and (2) improving coordination of care (to reduce unnecessary ED and inpatient use).

A simplified score to quantify comorbidity in COPD

IMPORTANCE

Comorbidities are common in COPD, but quantifying their burden is difficult. Currently there is a COPD-specific comorbidity index to predict mortality and another to predict general quality of life. We sought to develop and validate a COPD-specific comorbidity score that reflects comorbidity burden on patient-centered outcomes.

MATERIALS AND METHODS

Using the COPDGene study (GOLD II-IV COPD), we developed comorbidity scores to describe patient-centered outcomes employing three techniques: 1) simple count, 2) weighted score, and 3) weighted score based upon statistical selection procedure. We tested associations, area under the Curve (AUC) and calibration statistics to validate scores internally with outcomes of respiratory disease-specific quality of life (St. George's Respiratory Questionnaire, SGRQ), six minute walk distance (6MWD), modified Medical Research Council (mMRC) dyspnea score and exacerbation risk, ultimately choosing one score for external validation in SPIROMICS.

RESULTS

Associations between comorbidities and all outcomes were comparable across the three scores. All scores added predictive ability to models including age, gender, race, current smoking status, pack-years smoked and FEV1 (p<0.001 for all comparisons). Area under the curve (AUC) was similar between all three scores across outcomes: SGRQ (range 0·7624-0·7676), MMRC (0·7590-0·7644), 6MWD (0·7531-0·7560) and exacerbation risk (0·6831-0·6919). Because of similar performance, the comorbidity count was used for external validation. In the SPIROMICS cohort, the comorbidity count performed well to predict SGRQ (AUC 0·7891), MMRC (AUC 0·7611), 6MWD (AUC 0·7086), and exacerbation risk (AUC 0·7341).

CONCLUSIONS

Quantifying comorbidity provides a more thorough understanding of the risk for patient-centered outcomes in COPD. A comorbidity count performs well to quantify comorbidity in a diverse population with COPD.

Diagnoses, procedures, drug utilization, comorbidities, and cost of health care for people with epilepsy in 2012

Our objective was to identify the top MD-office, inpatient and outpatient diagnoses, procedures, drug classes, comorbidities, and cost of health care for people with epilepsy. We examined health insurance claims for 8388 persons with epilepsy (females = 52%, males = 48%; average age = 35 years; privately insured = 78%, and Medicaid-insured = 22%) from eight health insurance plans for the year 2012. All of the top three diagnoses for MD-office place of service were either for other convulsions (780.39) or for epilepsy (345.90 and 345.40). Two of the top three primary diagnosis codes from the inpatient hospital and emergency department places of service were 780.39 and 345.90 for convulsions and epilepsy, respectively, while the third code was 786.50 for chest pain. The top three procedures from the MD-office setting were for immunizations (90471 and 90658) and blood counts (85025). The top three procedure codes from the outpatient hospital setting were 85025 for complete blood count, 80053 for comprehensive metabolic panel, and 80048 for basic metabolic panel. In the emergency department, the top three procedures were electrocardiogram (93010), computed tomography (70450), and chest X-ray (71020). The top five drug classes among prescription drugs billed using an NDC code were (1) anticonvulsants, (2) analgesic-opioids, (3) antidepressants, (4) penicillins, and (5) dermatologicals. The mean monthly health plan paid cost for each patient with epilepsy in 2012 was $1028 (SD = $3181). Of this total, $761 (SD = $2988; 74%) was for medical, and $267 (SD = $760; 26%) was for prescription pharmacy claims. Fifty-eight percent (58%) of the patients had one or more of 29 prespecified comorbidities, while 42% had none. Monthly health-care costs increased markedly as the number of comorbidities increased. This information should help guide cost estimates and resource allocation in order to optimally care for people with epilepsy.

Premature mortality in poor health and low income adults with epilepsy

OBJECTIVE

To examine mortality and causes of death (CODs) in socioeconomically disadvantaged persons with epilepsy (PWEs) in the United States.

METHODS

We performed a retrospective open cohort analysis using Ohio Medicaid claims data between 1992 and 2008 to assess mortality and COD in 68,785 adult Medicaid beneficiaries with epilepsy. Case fatality (CF), mortality rates (MRs), standardized mortality ratios (SMRs), and years of potential life lost (YPLLs) were calculated. The SMRs were estimated to compare risk of death in PWEs with that in the general Medicaid population with and without disabilities. Proportionate mortality ratios (PMRs), YPLLs, and SMRs for specific COD were also obtained.

RESULTS

There were 12,630 deaths in PWEs. CF was 18.4%, the age-race-sex adjusted MR was 18.6/1,000 person-years (95% confidence interval [CI], 18.3-18.9). The SMR was 1.8 (95% CI, 1.8-1.9) when compared to the general Medicaid population, and was 1.4 (95% CI, 1.3-1.6) when compared to those with disabilities. The average YPLL was 16.9 years (range 1-47 years). Both epilepsy and comorbid conditions significantly contributed to premature mortality in PWEs. Cardiovascular diseases, cancer, and unintentional injuries were the most common COD and account for a large proportion of YPLLs. Deaths from epilepsy-related causes occurred in about 10% of the cases.

SIGNIFICANCE

Socioeconomically deprived PWEs, especially young adults, experience high mortality and die 17 years prematurely. The high mortality in Medicaid beneficiaries with epilepsy affirms that comorbid conditions and epilepsy play a crucial role in premature death. Management of comorbid conditions is, at a minimum, as important as epilepsy management, and therefore deserves more attention from physicians, particularly those who care for Medicaid beneficiaries with epilepsy.

Epidemiology of inflammatory bowel disease in Québec: recent trends

BACKGROUND

Among 10 provinces in Canada, Québec has the second highest incidence of Crohn's disease (CD), based on data collected more than a decade ago. To date, there are no reports on the occurrence of ulcerative colitis (UC) and no updates on the occurrence of CD in Québec. We sought to describe trends in the annual incidence and prevalence of inflammatory bowel disease in Québec during 2001 to 2008.

METHODS

A population-based retrospective cohort study was conducted using the administrative health databases of Québec. IBD cases were identified using a validated case definition requiring at least 1 hospitalization or 4 physician claims within a 2-year period. Incident cases were defined as individuals who had been free of inflammatory bowel disease for at least 2 years before the 2-year time span of the case definition.

RESULTS

We identified 24,377 CD and 15,346 UC cases. The mean age at diagnosis was 39 and 46 years for CD and UC, respectively. There was a significant decline in the annual incidence from 2001 to 2008 for both CD (P < 0.003) and UC (P < 0.001). No significant change with time was found in pediatric cases. The point prevalence in 2008 was 277 CD and 164 UC cases per 100,000 population. The average incidence was 17.4 CD cases per 100,000 person-years and 10.1 UC cases per 100,000 person-years. There was no predominance of urban or rural cases for either CD or UC.

CONCLUSIONS

During 2001 to 2008, annual incidence for both CD and UC declined in Québec. There was no significant change with time in incidence for pediatric cases.

Weight and fat distribution in patients taking valproate: a valproate-discordant gender-matched twin and sibling pair study

OBJECTIVES

Chronic treatment with valproate (VPA) is commonly associated with weight gain, which potentially has important health implications, in particular increased central fat distribution. We utilized a VPA-discordant same-sex, twin and matched sibling pair study design to primarily examine for differences in fat distribution between patients with epilepsy treated with VPA compared to their matched twin or sibling control. Weight, blood pressure, and leptin levels were assessed.

METHODS

Height, weight, waist and hip measurements, exercise, blood pressure (BP), and serum leptin levels were measured. Body composition was measured using dual-energy x-ray absorptiometry (DXA). Abdominal fat was expressed as a percentage of the abdominal region (AFat%); and of whole body fat (WBF); (AFat%WBF). Mean within-pair differences were assessed (VPA-user and nonuser). Restricted maximum likelihood (REML) linear mixed model analysis was fitted to examine associations of anthropometrics, zygosity, gender, menopausal status, VPA dose and duration, with weight and AFat%.

RESULTS

We studied 19 pairs of VPA-discordant, gender-matched (five male, 14 female) twins and siblings. Mean (standard deviation, SD) duration of therapy for VPA users was 11.0 (7.4) years. There were no statistically significant within-pair differences in age, height, weight, body mass index (BMI), BP, leptin level, WBF, AFat%, or AFat%WBF. For pairs in which VPA-user was treated for >11 years there were statistically significant mean within-pair differences in AFat%, (+7.1%, p = 0.03, n = 10 pairs), mean BP (+11.0 mm Hg, p = 0.006, n = 8 pairs); but not in AFat%WBF. VPA duration was positively associated with weight (estimate +0.98 kg/per year of VPA, p = 0.03); VPA treatment duration and dose were not significantly associated with AFat%.

SIGNIFICANCE

This study demonstrated a relationship between long-term VPA use and abdominal adiposity (AFat%), which could have significant health implications. We recommend ongoing monitoring of weight, BMI, and blood pressure for patients taking VPA.

Comorbidity in cirrhosis

Cirrhosis patients’ comorbidities are their other diseases than cirrhosis. Comorbidities are neither causes nor consequences of cirrhosis, but they can increase mortality and are therefore clinically important. They are also an important source of confounding in epidemiologic studies. Comorbidity scoring systems have been developed as tools to measure the cirrhosis patient’s total burden of comorbidity, and they are useful in the clinic and for epidemiologic studies. The recently developed CirCom score is the only comorbidity scoring system developed specifically for cirrhosis patients, and it may be preferred over the older, generic, and more complex Charlson comorbidity index. Studies of individual comorbid diseases can provide insight into the interactions between cirrhosis and other diseases and thus into the pathophysiology of cirrhosis. This article reviews the literature on comorbidity in cirrhosis.