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Watson MM, Kerr WT, Bean M, Strom L. Functional Seizure Clinics: A Proposed Financially Viable Solution to the Neurologist Supply and Demand Mismatch. Neurol Clin Pract 2023; 13:e200179. [PMID: 37529298 PMCID: PMC10389173 DOI: 10.1212/cpj.0000000000200179] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 05/23/2023] [Indexed: 08/03/2023]
Abstract
Background and Objectives Projections from recent studies suggest that by 2025, there will not be enough neurologists to meet the demand in 41 states. In this study, we investigate the financial impact and improved access to care for persons with epilepsy that is possible by implementing a multidisciplinary treatment clinic for persons with functional seizures (FS), previously referred to as psychogenic nonepileptic seizures, thus separating those patients out of an epilepsy clinic. Methods This observational retrospective study used real-time data of 156 patients referred to an FS clinic integrated into a tertiary care epilepsy center to simulate its effect on epilepsy division access and finances. Access was measured using simulations of the number of return patient visits (RPVs) and new patient visits (NPVs) of patients with FS to a dedicated epilepsy clinic, based on survey results inquiring about the standard of care without the FS clinic. Finances were simulated using the resultant access multiplied by respective wRVU and reimbursement per CPT code. Results Treatment of 156 patients with FS in a multidisciplinary FS clinic resulted in 343 newly opened NPVs, reimbursement of $102,000, and 1,200 wRVUs in our dedicated epilepsy clinic. There were 686 RPVs, $103,000 in reimbursement, and 1,320 wRVUs. Relative to the total number of NPVs with epilepsy clinic epileptologists, 343 NPVs represent a biennial 15.5% increase in available new patient visit slots. Discussion Our findings describe the financial viability of integrating a treatment clinic for persons with FS by directing them to FS-specialized treatment and thereby increasing access for patients with probable epilepsy to the dedicated epilepsy clinic. This study provides a potential solution to the national mismatch in the supply and demand of neurologists and an initial framework to use for those who wish to establish or integrate FS services in their institution.
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Affiliation(s)
- Meagan M Watson
- Department of Neurology (MMW, MB, LS), University of Colorado, Aurora; and Department of Neurology (WTK), University of Michigan, Ann Arbor
| | - Wesley T Kerr
- Department of Neurology (MMW, MB, LS), University of Colorado, Aurora; and Department of Neurology (WTK), University of Michigan, Ann Arbor
| | - Meagan Bean
- Department of Neurology (MMW, MB, LS), University of Colorado, Aurora; and Department of Neurology (WTK), University of Michigan, Ann Arbor
| | - Laura Strom
- Department of Neurology (MMW, MB, LS), University of Colorado, Aurora; and Department of Neurology (WTK), University of Michigan, Ann Arbor
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Garcia A. Pediatric Functional Neurologic Disorders. Pediatr Clin North Am 2023; 70:589-601. [PMID: 37121644 DOI: 10.1016/j.pcl.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Functional neurologic disorders are common in the pediatric population. Recently, there has been a renewed focus on functional neurologic disorders, leading to improvements in diagnosis and management. This review focuses on updates in clinical presentation, diagnosis, pathophysiology (including neuroimaging), and treatment of functional neurologic disorders in the pediatric population.
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Affiliation(s)
- Angela Garcia
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 1200, Pittsburgh, PA 15201, USA.
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3
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Onofrj M, Ajdinaj P, Digiovanni A, Malek N, Martinotti G, Ferro FM, Russo M, Thomas A, Sensi SL. Functional Neurologic Disorders, disorders to be managed by neurologists, or are neurologists wandering in a dangerous field with inadequate resources? Front Psychiatry 2023; 14:1120981. [PMID: 37009111 PMCID: PMC10064068 DOI: 10.3389/fpsyt.2023.1120981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/24/2023] [Indexed: 03/19/2023] Open
Abstract
In recent years, some neurologists reconsidered their approach to Medically Unexplained Symptoms and proposed Functional Neurologic Disorders (FND) as a new entity, claiming that neurology could offer alternative treatment options to the psychotherapies provided in psychiatry settings. FNDs, for this purpose, should include only the disorders listed as Conversion from the Somatic Symptom and Related Disorders (SSRD) group. The present review analyzes the rationale of this position and challenges the arguments provided for its support. The review also discusses the systematization of these disorders as provided by public health systems. It outlines risks stemming from economic support and public funding uncertainty, given their negligible epidemiological dimensions resulting from the parcellation of SSRD. The review underlines the unresolved issue of Factitious Disorders, which are in the same SSRD category of the international classification but are, nonetheless, overlooked by the theoretical proponents of the FND entity. Comorbidity with other psychiatric disorders is also analyzed. We propose a model that supports the continuum between different SSRD conditions, including Factitious Disorders. The model is based on the emergence of feigned death reflex and deception from frontal lobe dysfunction. Finally, the paper summarizes the wealth of historical psychiatric and psychodynamic approaches and critical reviews. The study also puts in context the categorization and interpretation efforts provided by the most eminent researchers of the past century.
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Affiliation(s)
- Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- *Correspondence: Marco Onofrj,
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Anna Digiovanni
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Naveed Malek
- Barking, Havering, and Redbridge University Hospitals NHS Trust, London, United Kingdom
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Department of Clinical, Pharmaceutical and Biological Sciences, University of Hertfordshire, Hertfordshire, United Kingdom
| | - Filippo Maria Ferro
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Astrid Thomas
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Stefano Luca Sensi
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
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4
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Yong K, Chin RFM, Shetty J, Hogg K, Burgess K, Lindsay M, McLellan A, Stone J, KamathTallur K. Functional neurological disorder in children and young people: Incidence, clinical features, and prognosis. Dev Med Child Neurol 2023. [PMID: 36752054 DOI: 10.1111/dmcn.15538] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 02/09/2023]
Abstract
AIM To report incidence, demographic and clinical characteristics, and symptom outcome of functional neurological disorder (FND) in children. METHOD Children diagnosed with FND at a regional children's hospital were prospectively recruited by weekly active surveillance for 36 months. Demographic, clinical, and follow-up data were retrospectively extracted by review of electronic records. Descriptive statistical analyses were used. RESULTS Ninety-seven children (age range 5-15 years) met the case definition of FND (annual incidence 18.3 per 100 000 children). Children with FND were likely to be female (n = 68 [70%]) and older (median 13 years) with no difference in the Scottish Index of Multiple Deprivation (marker of socioeconomic status) compared with the general childhood population. Functional motor (41%) and sensory (41%) symptoms were most common; other somatic symptoms such as headache (31%) and pain (27%) were frequent. Self-reported psychiatric symptoms and infection/inflammation were the most common predisposing and precipitating factors respectively. At a median of 15 months follow-up, 49% of 75 children reported improvement or resolution of FND symptoms with no prognostic factors found. INTERPRETATION At this regional centre, FND in children had a higher incidence than previously reported and a less optimistic outcome than in some other studies.
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Affiliation(s)
- Kenneith Yong
- Department of Clinical Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Richard F M Chin
- Department of Clinical Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK.,Child Life and Health, MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK.,Centre for Clinical Brain Sciences, University of Edinburgh Division of Health Sciences, Edinburgh, UK
| | - Jay Shetty
- Department of Clinical Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK.,Child Life and Health, MRC Centre for Reproductive Health, University of Edinburgh, Edinburgh, UK
| | - Kirsty Hogg
- Department of Clinical Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Kieran Burgess
- Department of Clinical Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Max Lindsay
- Department of Clinical Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Ailsa McLellan
- Department of Clinical Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh Division of Health Sciences, Edinburgh, UK
| | - Krishnaraya KamathTallur
- Department of Clinical Neurosciences, Royal Hospital for Children and Young People, Edinburgh, UK
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Kline CL, Shamshair S, Kullgren KA, Leber SM, Malas N. A Review of the Impact of Sociodemographic Factors on the Assessment and Management of Pediatric Somatic Symptom and Related Disorders. J Acad Consult Liaison Psychiatry 2023; 64:58-64. [PMID: 36328180 DOI: 10.1016/j.jaclp.2022.10.266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/11/2022] [Accepted: 10/25/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND While factors such as race, sex, gender identity, and socioeconomic status impact the diagnosis and treatment of a variety of conditions, there are few studies examining their influence on somatic symptom and related disorders (SSRDs), particularly in the pediatric population. OBJECTIVE In this review, we outline the existing literature on how sociodemographic characteristics influence the overall care of pediatric SSRDs. Throughout this literature review, we highlight opportunities for further research, including potential disparities in evaluation, management, and outcomes along several sociodemographic domains. METHODS We conducted a thorough review of the evidence for potential impact of race, sex, gender identity, and socioeconomic status on the presentation, diagnosis, management, and outcomes of pediatric somatization and SSRDs. RESULTS Recent studies evaluating the impact of race on SSRD care suggest the potential for provider bias in the evaluation and management of this population based on racial differences in diagnostic evaluations. Somatization may present differently based on a patient's race and potential cross-cultural status. Among studies of cisgender patients, there is evidence of provider bias in the assessment of somatic symptoms such that female patients are more likely to be diagnosed with an SSRD than male patients. However, there is little research among youth identifying as LGBTQ. The literature also indicates that low socioeconomic status and associated stressors are linked with the development of SSRDs, although it is unclear whether these factors are subject to bias by providers. CONCLUSIONS While the literature is sparse, there is evidence that sociodemographic factors contribute to differences in diagnosis, evaluation, and management of pediatric SSRDs. These factors, particularly race and sex, may also be subject to provider bias, although further studies are necessary. Provider bias can directly impact patients' perception of care, including feelings of dismissal, and may have downstream influences on symptom manifestation, patient-provider engagement, diagnostic evaluation, and management practices.
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Affiliation(s)
| | - Saad Shamshair
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
| | | | | | - Nasuh Malas
- Department of Psychiatry, University of Michigan, Ann Arbor, MI
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