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Moura L, Karakis I, Howard D. Emergency department utilization among adults with epilepsy: A multi-state cross-sectional analysis, 2010-2019. Epilepsy Res 2024; 205:107427. [PMID: 39116513 DOI: 10.1016/j.eplepsyres.2024.107427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 07/08/2024] [Accepted: 08/05/2024] [Indexed: 08/10/2024]
Abstract
OBJECTIVE We described patterns and trends in ED use among adults with epilepsy in the United States. METHODS Utilizing inpatient and ED discharge data from seven states, we conducted a cross-sectional analysis to identify adult ED visits diagnosed with epilepsy or seizures from 2010 to 2019. Using ED visit counts and estimates of state-level epilepsy prevalence, we calculated ED visit rates overall and by payer, condition, and year. RESULTS Our data captured 304,935 ED visits with epilepsy as a primary or secondary diagnosis in 2019. Across the seven states, visit rates ranged between 366 and 726 per 1000 and were higher than rates for adults without epilepsy in all states but one. ED visit rates were highest among Medicare and Medicaid beneficiaries (vs commercial or self-pay). Adults with epilepsy were more likely to be admitted as inpatients. Visits for nervous system disorders were 6.3-8.2 times higher among people with epilepsy, and visits for mental health conditions were 1.2-2.6 times higher. Increases in ED visit rates from 2010 to 2019 among people with epilepsy exceeded increases among adults without by 6.0-27.3 percentage points. CONCLUSION Adults with epilepsy visit the ED frequently and visit rates have been increasing over time. These results underscore the importance of identifying factors contributing to ED use and designing tailored interventions to improve ambulatory care quality.
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Affiliation(s)
- Lidia Moura
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA; Department of Neurology, Harvard Medical School, Boston, MA, USA.
| | - Ioannis Karakis
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia; University of Crete School of Medicine, Heraklion, Greece
| | - David Howard
- Department of Health Policy, Emory University School of Medicine, Atlanta, Georgia
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Nummedal MA, King S, Uleberg O, Pedersen SA, Bjørnsen LP. Non-emergency department (ED) interventions to reduce ED utilization: a scoping review. BMC Emerg Med 2024; 24:117. [PMID: 38997631 PMCID: PMC11242019 DOI: 10.1186/s12873-024-01028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Emergency department (ED) crowding is a global burden. Interventions to reduce ED utilization have been widely discussed in the literature, but previous reviews have mainly focused on specific interventions or patient groups within the EDs. The purpose of this scoping review was to identify, summarize, and categorize the various types of non-ED-based interventions designed to reduce unnecessary visits to EDs. METHODS This scoping review followed the JBI Manual for Evidence Synthesis and the PRISMA-SCR checklist. A comprehensive structured literature search was performed in the databases MEDLINE and Embase from 2008 to March 2024. The inclusion criteria covered studies reporting on interventions outside the ED that aimed to reduce ED visits. Two reviewers independently screened the records and categorized the included articles by intervention type, location, and population. RESULTS Among the 15,324 screened records, we included 210 studies, comprising 183 intervention studies and 27 systematic reviews. In the primary studies, care coordination/case management or other care programs were the most commonly examined out of 15 different intervention categories. The majority of interventions took place in clinics or medical centers, in patients' homes, followed by hospitals and primary care settings - and targeted patients with specific medical conditions. CONCLUSION A large number of studies have been published investigating interventions to mitigate the influx of patients to EDs. Many of these targeted patients with specific medical conditions, frequent users and high-risk patients. Further research is needed to address other high prevalent groups in the ED - including older adults and mental health patients (who are ill but may not need the ED). There is also room for further research on new interventions to reduce ED utilization in low-acuity patients and in the general patient population.
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Affiliation(s)
- Målfrid A Nummedal
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sarah King
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Oddvar Uleberg
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Sindre A Pedersen
- The Medicine and Health Library, Library Section for Research Support, Data and Analysis, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Lars Petter Bjørnsen
- Trondheim Emergency Department Research Group (TEDRG), Department of Circulation and Medical Imaging, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Clinic of Emergency Medicine and Prehospital Care, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Mitchell JW, Sossi F, Miller I, Jaber PB, Das-Gupta Z, Fialho LS, Amos A, Austin JK, Badzik S, Baker G, Ben Zeev B, Bolton J, Chaplin JE, Cross JH, Chan D, Gericke CA, Husain AM, Lally L, Mbugua S, Megan C, Mesa T, Nuñez L, von Oertzen TJ, Perucca E, Pullen A, Ronen GM, Sajatovic M, Singh MB, Wilmshurst JM, Wollscheid L, Berg AT. Development of an International Standard Set of Outcomes and Measurement Methods for Routine Practice for Infants, Children, and Adolescents with Epilepsy: The International Consortium for Health Outcomes Measurement Consensus Recommendations. Epilepsia 2024; 65:1938-1961. [PMID: 38758635 DOI: 10.1111/epi.17976] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 05/19/2024]
Abstract
At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. The International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy, and their representatives to develop minimum sets of standardized outcomes and outcome measurement methods for clinical practice. Using modified Delphi consensus methods with consecutive rounds of online voting over 12 months, a core set of outcomes and corresponding measurement tool packages to capture the outcomes were identified for infants, children, and adolescents with epilepsy. Consensus methods identified 20 core outcomes. In addition to the outcomes identified for the ICHOM Epilepsy adult standard set, behavioral, motor, and cognitive/language development outcomes were voted as essential for all infants and children with epilepsy. The proposed set of outcomes and measurement methods will facilitate the implementation of the use of patient-centered outcomes in daily practice.
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Affiliation(s)
- James W Mitchell
- Institute of Systems, Molecular, and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Frieda Sossi
- International Consortium for Health Outcomes Measurement, London, UK
| | - Isabel Miller
- International Consortium for Health Outcomes Measurement, London, UK
| | | | - Zofia Das-Gupta
- International Consortium for Health Outcomes Measurement, London, UK
| | - Luz Sousa Fialho
- International Consortium for Health Outcomes Measurement, London, UK
| | - Action Amos
- International Bureau for Epilepsy, Africa Region, University of Edinburgh, Edinburgh, UK
| | - Joan K Austin
- Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Scott Badzik
- Lived experience representative, Cincinnati, Ohio, USA
| | - Gus Baker
- University of Liverpool, Liverpool, UK
| | - Bruria Ben Zeev
- Sheba Medical Center, Edmond and Lilly Safra Children's Hospital, Tel Hashomer, Israel
| | | | | | - J Helen Cross
- Developmental Neurosciences Department, University College London Great Ormond Street Institute of Child Health, London, UK
| | - Derrick Chan
- KK Women's and Children's Hospital, Duke-NUS, Singapore, Singapore
| | | | - Aatif M Husain
- Duke University Medical Center and Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Lorraine Lally
- LLM (International Human Rights Law), LLM (Financial Services Law), Galway, Ireland
| | | | | | - Tomás Mesa
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lilia Nuñez
- Centro Medico Nacional 20 de Noviembre, Médica Sur, Mexico City, Mexico
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Emilio Perucca
- Department of Medicine (Austin Health), University of Melbourne, Melbourne, Victoria, Australia
| | | | - Gabriel M Ronen
- Department of Pediatrics, CanChild Centre for Childhood Disability Research, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Martha Sajatovic
- Departments of Psychiatry and Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mamta B Singh
- All Indian Institute of Medicine Sciences, New Delhi, India
| | - Jo M Wilmshurst
- Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | | | - Anne T Berg
- Department of Neurology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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4
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Mitchell JW, Sossi F, Miller I, Jaber PB, Das-Gupta Z, Fialho LS, Amos A, Austin JK, Badzik S, Baker G, Zeev BB, Bolton J, Chaplin JE, Cross JH, Chan D, Gericke CA, Husain AM, Lally L, Mbugua S, Megan C, Mesa T, Nuñez L, von Oertzen TJ, Perucca E, Pullen A, Ronen GM, Sajatovic M, Singh MB, Wilmshurst JM, Wollscheid L, Berg AT. Development of an International Standard Set of Outcomes and Measurement Methods for Routine Practice for Adults with Epilepsy: The International Consortium for Health Outcomes Measurement Consensus Recommendations. Epilepsia 2024; 65:1916-1937. [PMID: 38738754 DOI: 10.1111/epi.17971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 05/14/2024]
Abstract
At present, there is no internationally accepted set of core outcomes or measurement methods for epilepsy clinical practice. Therefore, the International Consortium for Health Outcomes Measurement (ICHOM) convened an international working group of experts in epilepsy, people with epilepsy and their representatives to develop minimum sets of standardized outcomes and outcomes measurement methods for clinical practice that support patient-clinician decision-making and quality improvement. Consensus methods identified 20 core outcomes. Measurement tools were recommended based on their evidence of strong clinical measurement properties, feasibility, and cross-cultural applicability. The essential outcomes included many non-seizure outcomes: anxiety, depression, suicidality, memory and attention, sleep quality, functional status, and the social impact of epilepsy. The proposed set will facilitate the implementation of the use of patient-centered outcomes in daily practice, ensuring holistic care. They also encourage harmonization of outcome measurement, and if widely implemented should reduce the heterogeneity of outcome measurement, accelerate comparative research, and facilitate quality improvement efforts.
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Affiliation(s)
- James W Mitchell
- Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK
| | - Frieda Sossi
- International Consortium for Health Outcomes Measurement, London, UK
| | - Isabel Miller
- International Consortium for Health Outcomes Measurement, London, UK
| | | | - Zofia Das-Gupta
- International Consortium for Health Outcomes Measurement, London, UK
| | - Luz Sousa Fialho
- International Consortium for Health Outcomes Measurement, London, UK
| | - Action Amos
- International Bureau for Epilepsy, Africa Region, University of Edinburgh, Edinburgh, UK
| | - Joan K Austin
- Indiana University School of Nursing, Indianapolis, Indiana, USA
| | - Scott Badzik
- Lived Experience Representative, Cincinnati, Ohio, USA
| | - Gus Baker
- University of Liverpool, Liverpool, UK
| | - Bruria Ben Zeev
- The Edmond and Lilly Safra Children's Hospital, Sheba Medical Center, Tel Hashomer, Israel
| | | | | | - J Helen Cross
- Developmental Neurosciences Dept, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Derrick Chan
- KK Women's and Children's Hospital, Duke-NUS, Singapore
| | - Christian A Gericke
- The University of Queensland Medical School, Brisbane, Queensland, Australia
| | - Aatif M Husain
- Duke University Medical Center and Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - Lorraine Lally
- LLM (International Human Rights Law), LLM (Financial Services Law), Galway, Ireland
| | | | | | - Tomás Mesa
- Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Lilia Nuñez
- Centro Medico Nacional 20 de Noviembre, Médica Sur, Mexico City, Mexico
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler University Hospital, Johannes Kepler University, Linz, Austria
| | - Emilio Perucca
- Department of Medicine (Austin Health), The University of Melbourne, Melbourne, Victoria, Australia
| | | | - Gabriel M Ronen
- Department of Pediatrics, CanChild Centre for Childhood Disability Research, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Martha Sajatovic
- Departments of Psychiatry and of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Mamta B Singh
- All Indian Institute of Medicine Sciences, New Delhi, India
| | - Jo M Wilmshurst
- Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | | | - Anne T Berg
- Department of Neurology, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
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5
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Gumayan RL, Parker W, Gunduz MT, Aylward SC, Auer N, Albert DVF, Patel AD. Increasing Provider Utilization of a Seizure Action Plan in the Outpatient Setting. Pediatrics 2024; 154:e2023061268. [PMID: 38899390 DOI: 10.1542/peds.2023-061268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 04/11/2024] [Indexed: 06/21/2024] Open
Abstract
OBJECTIVES A seizure action plan (SAP) is a powerful tool that provides actionable information for caregivers during seizures. Guidelines have expressed the need for individualized SAPs. Our quality improvement team aimed to increase implementation of an SAP within a pediatric tertiary center, initially among epilepsy providers and expanded to all neurology providers. METHODS Process changes were implemented using Plan-Do-Study-Act cycles and data were evaluated monthly using control charts. The team focused on tracking patients who received SAPs and identified opportunities for improvement, including reminders within the electronic medical record, and standardizing clinic processes. A secondary analysis was performed to trend emergency department (ED) use among our patient population. RESULTS The SAP utilization rate among epilepsy providers increased from a baseline of 39% to 78% by December 2019 and reached the goal of 85% by June 2020, with a further increase to 92% by February 2022 and maintained. The SAP utilization rate among general neurology providers increased from 43% in 2018 to 85% by July 2020, and further increased to 93% by February 2022 and maintained. ED visits of established patients with epilepsy decreased from a baseline of 10.2 per 1000 to 7.5 per 1000. CONCLUSIONS Quality improvement methodologies increased the utilization of a standardized SAP within neurology outpatient care centers. The SAP is a simplified tool that allows patients and providers to navigate a complex health care system. The utility of an SAP may potentially extend to minimizing unnecessary ED visits.
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Affiliation(s)
- Rae Leonor Gumayan
- Zickler Family Prenatal Pediatrics Institute, Children's National Hospital, Washington, District of Columbia
| | - William Parker
- The Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
| | - Muhammed Talha Gunduz
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio
| | - Shawn C Aylward
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio
| | - Nancy Auer
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio
| | - Dara V F Albert
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio
| | - Anup D Patel
- The Center for Clinical Excellence, Nationwide Children's Hospital, Columbus, Ohio
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University, Columbus, Ohio
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Ettienne EB, Russo E, Striano P, Grant-Kels JM, Rose K. Did pediatric drug development advance epilepsy treatment in young patients? It is time for new research goals. World J Methodol 2024; 14:92371. [PMID: 38983658 PMCID: PMC11229878 DOI: 10.5662/wjm.v14.i2.92371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/13/2024] [Accepted: 04/16/2024] [Indexed: 06/13/2024] Open
Abstract
Modern drugs have changed epilepsy, which affects people of all ages. However, for young people with epilepsy, the framework of drug development has stalled. In the wake of the thalidomide catastrophe, the misconception emerged that for people < 18 years of age drugs, including antiseizure medications (ASMs), need separate proof of efficacy and safety, overall called "pediatric drug development". For ASMs, this has changed to some degree. Authorities now accept that ASMs are effective in < 18 years as well, but they still require "extrapolation of efficacy," as if minors were another species. As a result, some of the pediatric clinical epilepsy research over the past decades was unnecessary. Even more importantly, this has hampered research on meaningful research goals. We do not need to confirm that ASMs work before as they do after the 18th birthday. Instead, we need to learn how to prevent brain damage in young patients by preventing seizures and optimize ASMs' uses. Herein we discuss how to proceed in this endeavor.
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Affiliation(s)
- Earl B Ettienne
- College of Pharmacy, Howard University College of Pharmacy, Washington, DC 20059, United States
| | - Emilio Russo
- Department of Health Sciences, School of Medicine, Russo, University "Magna Graecia" of Catanzaro, Catanzaro 88100, Italy
| | | | - Jane M Grant-Kels
- Department of Dermatology, University of Connecticut Health Center, Farmington, CT 06032, United States
| | - Klaus Rose
- klausrose Consulting, Pediatric Drug Development and more, Medical Science, CH-4125 Riehen, Switzerland
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Lee YT, Lai YW, Chen JH, Chen WL, Wu MY, Chung JY. Assessing the Impact of the COVID-19 Pandemic on Pediatric Emergency Department Visits in Taiwan. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:288. [PMID: 38399575 PMCID: PMC10890672 DOI: 10.3390/medicina60020288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 01/29/2024] [Accepted: 02/02/2024] [Indexed: 02/25/2024]
Abstract
Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted healthcare systems worldwide. To assess the effects of the pandemic on pediatric emergency department (ED) visits in Taiwan, we conducted a study to evaluate changes in pediatric ED visits during the COVID-19 pandemic. Materials and Methods: This retrospective study included pediatric patients (age ≤ 18) who visited the ED between 21 January 2019 and 30 April 2019, at three hospitals of the Cathay Health System, and compared them with a corresponding period in 2020. Basic information, including mode of arrival, triage level, disposition, chief complaints, and incidence rates, were analyzed before and during the pandemic. Results: A total of 10,116 patients, with 6009 in the pre-pandemic group and 4107 in the pandemic group, were included in this study. The mean number of daily pediatric ED visits decreased from 60.09 before the pandemic to 40.66 during the pandemic, while ambulance use increased significantly by 2.56%. The percentage of patients with high acuity triage levels (levels 1 and 2) was significantly lower during the pandemic period (0.63% and 10.18%, respectively) than the pre-pandemic period (0.7% and 10.9%, respectively). Additionally, a significantly higher proportion of patients were discharged during the pandemic period (89.36%) than during the pre-pandemic period (88.33%). The proportion of COVID-19-related complaints, such as fever and respiratory tract infections, as well as other complaints including gastrointestinal issues, trauma, and psychological problems, significantly increased during the pandemic. Conclusions: In preparation for future pandemics, we recommend increasing emergency medical service capacity, establishing a non-contagious route for obtaining chronic medication prescriptions, optimizing staff allocation in pediatric emergency departments, and increasing the number of hospital social workers for enhanced support.
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Affiliation(s)
- Yu-Ting Lee
- Department of Emergency Medicine, Cathay General Hospital, Taipei 106438, Taiwan; (Y.-T.L.); (J.-H.C.); (W.-L.C.)
- Department of Emergency Medicine, Sijhih Cathay General Hospital, New Taipei City 221037, Taiwan;
| | - Yen-Wen Lai
- Department of Emergency Medicine, Sijhih Cathay General Hospital, New Taipei City 221037, Taiwan;
| | - Jiann-Hwa Chen
- Department of Emergency Medicine, Cathay General Hospital, Taipei 106438, Taiwan; (Y.-T.L.); (J.-H.C.); (W.-L.C.)
- School of Medicine, Fu Jen Catholic University, Taipei 242062, Taiwan
| | - Wei-Lung Chen
- Department of Emergency Medicine, Cathay General Hospital, Taipei 106438, Taiwan; (Y.-T.L.); (J.-H.C.); (W.-L.C.)
- School of Medicine, Fu Jen Catholic University, Taipei 242062, Taiwan
| | - Meng-Yu Wu
- Department of Emergency Medicine, Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City 231016, Taiwan
- School of Medicine, Tzu Chi University, Hualien 970374, Taiwan
| | - Jui-Yuan Chung
- Department of Emergency Medicine, Cathay General Hospital, Taipei 106438, Taiwan; (Y.-T.L.); (J.-H.C.); (W.-L.C.)
- School of Medicine, National Tsing Hua University, Hsinchu 300044, Taiwan
- Department of Education, Cathay General Hospital, Taipei 106438, Taiwan
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Osborne G, Valenti O, Jarvis J, Wentzel E, Vidaurre J, Clarke DF, Patel AD. Implementing American Academy of Neurology Quality Measures in Antigua Using Quality Improvement Methodology. Neurol Clin Pract 2024; 14:e200231. [PMID: 38152065 PMCID: PMC10751012 DOI: 10.1212/cpj.0000000000200231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/10/2023] [Indexed: 12/29/2023]
Abstract
Background and Objectives The American Academy of Neurology has developed quality measures related to various neurologic disorders. A gap exists in the implementation of these measures in the different health care systems. To date, there has been no electronic health care record nor implementation of quality measures in Antigua. Therefore, we aimed to increase the percent of patients who have epilepsy quality measures documented using standardized common data elements in the outpatient neurology clinic at Sir Lester Bird Medical Center from 0% to 80% per week by June 1, 2022 and sustain for 6 months. Methods We used the Institute for Health care Improvement Model for Improvement methodology. A data use agreement was implemented. Data were displayed using statistical process control charts and the American Society for Quality criteria to determine statistical significance and centerline shifts. Results Current and future state process maps were developed to determine areas of opportunity for interventions. Interventions were developed following a "Plan-Do-Study-Act cycle." One intervention was the creation of a RedCap survey and database to be used by health care providers during clinical patient encounters. Because of multiple interventions, we achieved a 100% utilization of the survey for clinical care. Discussion Quality improvement (QI) methodology can be used for implementation of quality measures in various settings to improve patient care outcomes without use of significant resources. Implementation of quality measures can increase efficiency in clinical delivery. Similar QI methodology could be implemented in other resource-limited countries of the Caribbean and globally.
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Affiliation(s)
- Gaden Osborne
- Neurology Department (GO, JJ), Sir Lester Bird Medical Centre, St. John's, Antigua, West Indies; The Center for Clinical Excellence (OV, ADP); Division of Neurology (EW, JV, ADP), Nationwide Children's Hospital, Columbus, OH; and Pediatric Neurology (DFC), Dell Medical School, the University of Texas at Austin
| | - Olivia Valenti
- Neurology Department (GO, JJ), Sir Lester Bird Medical Centre, St. John's, Antigua, West Indies; The Center for Clinical Excellence (OV, ADP); Division of Neurology (EW, JV, ADP), Nationwide Children's Hospital, Columbus, OH; and Pediatric Neurology (DFC), Dell Medical School, the University of Texas at Austin
| | - Juniella Jarvis
- Neurology Department (GO, JJ), Sir Lester Bird Medical Centre, St. John's, Antigua, West Indies; The Center for Clinical Excellence (OV, ADP); Division of Neurology (EW, JV, ADP), Nationwide Children's Hospital, Columbus, OH; and Pediatric Neurology (DFC), Dell Medical School, the University of Texas at Austin
| | - Evelynne Wentzel
- Neurology Department (GO, JJ), Sir Lester Bird Medical Centre, St. John's, Antigua, West Indies; The Center for Clinical Excellence (OV, ADP); Division of Neurology (EW, JV, ADP), Nationwide Children's Hospital, Columbus, OH; and Pediatric Neurology (DFC), Dell Medical School, the University of Texas at Austin
| | - Jorge Vidaurre
- Neurology Department (GO, JJ), Sir Lester Bird Medical Centre, St. John's, Antigua, West Indies; The Center for Clinical Excellence (OV, ADP); Division of Neurology (EW, JV, ADP), Nationwide Children's Hospital, Columbus, OH; and Pediatric Neurology (DFC), Dell Medical School, the University of Texas at Austin
| | - Dave F Clarke
- Neurology Department (GO, JJ), Sir Lester Bird Medical Centre, St. John's, Antigua, West Indies; The Center for Clinical Excellence (OV, ADP); Division of Neurology (EW, JV, ADP), Nationwide Children's Hospital, Columbus, OH; and Pediatric Neurology (DFC), Dell Medical School, the University of Texas at Austin
| | - Anup D Patel
- Neurology Department (GO, JJ), Sir Lester Bird Medical Centre, St. John's, Antigua, West Indies; The Center for Clinical Excellence (OV, ADP); Division of Neurology (EW, JV, ADP), Nationwide Children's Hospital, Columbus, OH; and Pediatric Neurology (DFC), Dell Medical School, the University of Texas at Austin
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9
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Muthiah N, Rothenberger S, Abel TJ. Socioeconomic status and healthcare utilization disparities among children with epilepsy in the United States: Results from a nationally representative sample. Sci Rep 2023; 13:21776. [PMID: 38066038 PMCID: PMC10709331 DOI: 10.1038/s41598-023-48668-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
Epilepsy affects 1% of the US population. Healthcare disparities are well-studied among adults with epilepsy but less so among children. We examined whether children with epilepsy (1) have lower income than or (2) utilize the emergency department (ED) differently from children without epilepsy, and (3) if income moderates ED utilization. Data from the 2016-2019 National Survey of Children's Health were used to identify children with active "epilepsy or seizure disorder". Children with versus without epilepsy were compared. Income and ED visits were modeled with logistic and Poisson regressions. This analysis included 131,326 children; 835 were diagnosed with epilepsy. Estimated population prevalence of epilepsy was 0.6%. Children from higher-income-households were less likely to have epilepsy (aOR: 0.7). Children with epilepsy were more likely to visit EDs (aOR = 10.2), see healthcare professionals (aOR: 2.7), and receive care from specialists (aOR: 10.3). Income moderated the relationship between having epilepsy and ED visits. 7.7% of children with epilepsy did not receive needed healthcare. Some barriers were acquiring appointments (aOR: 3.9) and transportation (aOR: 4.7). In conclusion, children with epilepsy were more likely than children without epilepsy to live in lower-income-households, visit EDs, see healthcare professionals, and not receive needed healthcare. Barrier-specific policy interventions may improve medical access for children with epilepsy.
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Affiliation(s)
- Nallammai Muthiah
- Department of Neurological Surgery, Washington University in Saint Louis School of Medicine, Saint Louis, USA
| | - Scott Rothenberger
- Department of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Taylor J Abel
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, 4401 Penn Ave, Pittsburgh, PA, 15224, USA.
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Philpott NG, Dante SA, Philpott D, Perin J, Bhatia P, Henderson E, Costabile P, Stratton M, Dabrowski A, Kossoff EH, Klein BL, Noje C. Treatment Guideline Nonadherence Pretransport Associated With Need for Higher Level of Care in Children Transferred to a Pediatric Tertiary Care Center for Status Epilepticus. Pediatr Emerg Care 2023; 39:780-785. [PMID: 37163683 DOI: 10.1097/pec.0000000000002952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES We sought to investigate the association between adherence to the American Epilepsy Society (AES) 2016 guidelines for management of convulsive status epilepticus (SE) and clinical outcomes among children requiring interhospital transport for SE. We hypothesized that pretransport guideline nonadherence would be associated with needing higher level of care posttransfer. METHODS This was a retrospective cohort study of children aged 30 days to 18 years transferred to our pediatric tertiary center from 2017 to 2019 for management of SE. Their care episodes were classified as 2016 American Epilepsy Society guideline adherent or nonadherent. There were 40 referring hospitals represented in this cohort. RESULTS Of 260 care episodes, 55 (21%) were guideline adherent, 184 (71%) were guideline nonadherent, and 21 (8%) had insufficient data to determine guideline adherence. Compared with the adherent group, patients in the nonadherent care group had longer hospitalizations (32 hours [17-68] vs 21 hours [7-48], P = 0.006), were more likely to require intensive care unit admission (47% vs 31%), and less likely to be discharged home from the emergency department (16% vs 35%; χ 2 test, P = 0.01). Intubation rates did not differ significantly between groups (25% vs 18%, P = 0.37). When we fit a multivariable model to adjust for confounding variables, guideline nonadherence was associated with need for higher level of care (odds ratio, 2.04; 95% confidence interval, 1.04-3.99). Treatment guideline adherence did not improve over the 3-year study period (2017: 22%, 2018: 19%, 2019: 29% [χ 2 test for differences between any 2 years, P = 0.295]). CONCLUSIONS Guideline nonadherence pretransport was associated with longer hospitalizations and need for higher level of care among children transferred for SE at our institution. These findings suggest a need to improve SE guideline adherence through multifaceted quality improvement efforts targeting both the prehospital and community hospital settings.
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Affiliation(s)
- Natalia Garza Philpott
- From the Department of Pediatrics. Johns Hopkins University School of Medicine, Baltimore, MD
| | - Siddhartha A Dante
- Department of Pediatrics, University of Maryland School of Medicine. Baltimore, MD
| | - David Philpott
- From the Department of Pediatrics. Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jamie Perin
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
| | - Pooja Bhatia
- Pediatric Transport, Johns Hopkins Children's Center, Baltimore, MD
| | - Eric Henderson
- Pediatric Transport, Johns Hopkins Children's Center, Baltimore, MD
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11
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Amin A, McCreary M, Dewey C, Hall C. Characterization of potentially avoidable neurological emergency department visits at a large urban public hospital. Proc AMIA Symp 2023; 36:186-189. [PMID: 36876255 PMCID: PMC9980619 DOI: 10.1080/08998280.2022.2147393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
This study characterized potentially avoidable neurological emergency department (ED) visits at a large urban public hospital. This was a retrospective review of Parkland Health (Dallas, TX) data from May 15, 2021, to July 15, 2021. The study population included encounters discharged home from the ED with any of the following: a primary neurological ED diagnosis, a neurological consultation in the ED, or a neurology clinic referral placed during the ED encounter. Neurovascular, strokelike, acute trauma, and nonneurological cases were excluded. The primary outcome was the number of ED visits by diagnosis category. A total of 965 ED discharge encounters met study criteria as potentially avoidable neurological ED visits, far higher than total neurology-related admissions over the same 2-month period. Headache (66%) and seizure/epilepsy (18%) syndromes were the most common. Thirty-five percent of all cases had neurology involvement in either the ED or the outpatient setting. This was lowest for headache (19%). The revisit rate within 3 months of the index ED visit was 29%, and it was highest for seizures/epilepsy (48%). Potentially avoidable nonvascular neurological ED visits occur frequently, especially for headache and seizure disorders. This study highlights the need for quality improvement and delivery innovation initiatives to optimize the site of care for patients with chronic neurological conditions.
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Affiliation(s)
- Anik Amin
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas.,Department of Neurology, Parkland Health, Dallas, Texas
| | - Morgan McCreary
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
| | - Chadrick Dewey
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
| | - Christiana Hall
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas.,Department of Neurology, Parkland Health, Dallas, Texas
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12
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Balk A, Weilburg JB, Lee J. Reducing Emergency Department Utilization. Hosp Pediatr 2022; 12:e449-e451. [PMID: 36366928 DOI: 10.1542/hpeds.2022-006831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Adi Balk
- Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheva, Israel
| | | | - Jarone Lee
- Associate Professor, Departments of Surgery and Emergency Medicine, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
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13
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Chuah A, Ding K, Morgado A, McCreary M, Zuberi F, Agostini M, Doyle A. Effects of psychiatric comorbidities in persons with epilepsy on recurrent emergency department visits. Epilepsy Behav 2022; 136:108909. [PMID: 36152383 DOI: 10.1016/j.yebeh.2022.108909] [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: 03/31/2022] [Revised: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Coexisting mental health disorders in persons with epilepsy present as substantial burdens to patients and healthcare systems. STUDY DESIGN AND METHODS In this retrospective study, we reviewed 160 patients presenting to a safety net hospital Emergency Department (ED) with seizures to investigate whether differences in clinical workup, follow-ups, and ED visit recurrence existed between epilepsy patients with epilepsy with and without a coexisting psychiatric disorder. RESULTS Patients with epilepsy with a psychiatric comorbidity had more subsequent ED visits (45 % vs 26 %, p = 0.01) and fewer outpatient follow-up opportunities (74 % vs 87 %, p = 0.042) compared to patients with epilepsy without psychiatric comorbidities, highlighting a healthcare gap that needs to be addressed. INTERPRETATION Our findings suggest a need for ED providers to shift their clinical practice in favor of offering more outpatient follow-up opportunities, to ensure long-term management of seizures in patients with epilepsy with comorbid psychiatric disorders.
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Affiliation(s)
- Ashleigh Chuah
- UT Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Kan Ding
- UT Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Anika Morgado
- UT Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Morgan McCreary
- UT Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Fatima Zuberi
- UT Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Mark Agostini
- UT Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
| | - Alexander Doyle
- UT Southwestern Medical Center, Department of Neurology, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
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14
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Hall JE, Pham PK, Liberman DB. Describing the Patient Population of a Pediatric Emergency Department Based on Visit Frequency. Pediatr Emerg Care 2022; 38:e1620-e1625. [PMID: 36173434 DOI: 10.1097/pec.0000000000002615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization. METHODS A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (<4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization. RESULTS In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration. CONCLUSIONS Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.
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15
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Yoon S, Goh H, Foo CP, Kao MIM, Hie SL, Chan SL, Krishnappa J, Ngoh ASF, Ling SR, Yeo TH, Chan DWS. Parents' priorities for decision-making of pediatric epilepsy treatments and perceived needs for decision support in multi-ethnic Asian clinical setting: A qualitative analysis. Epilepsy Behav 2022; 135:108880. [PMID: 35986955 DOI: 10.1016/j.yebeh.2022.108880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 08/08/2022] [Accepted: 08/08/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To identify parents' priorities when making a decision on genetic testing and antiseizure drug (ASD) options for pediatric epilepsy and their support needs for informed decision-making in multi-ethnic Asian clinical settings. METHODS Qualitative in-depth interviews, using a semi-structured interview guide, were conducted with purposively selected parents of pediatric patients with newly diagnosed epilepsy or known diagnosis of epilepsy (n = 26). Interviews were audio recorded and transcribed verbatim. Thematic analysis was undertaken to generate themes. RESULTS Parents' narratives showed difficulty assimilating information, while knowledge deficit and emotional vulnerability led parents' desire to defer a decision for testing and ASDs to mitigate decisional burden. Priorities for decisions were primarily based on intuitive ideas of the treatment's risks and benefits, yet very few could elaborate on tradeoffs between risks and efficacy. Priorities outside the purview of the healthcare team, such as children's emotional wellbeing and family burden of ASD administration, were also considered important. Authority-of-medical-professional heuristic facilitated the ASD decision for parents who preferred shared rather than sole responsibility for a decision. Importantly, parents' support needs for informed decision-making were very much related to the availability of support mechanisms in post-treatment decisions owing to perceived uncertainty of the chosen ASD. CONCLUSIONS Findings suggest that multiple priorities influenced ASD decision process. To address support needs of parents for informed decision-making, more consideration should be given to post-treatment decision support through the provision of educational opportunities, building peer support networks, and developing a novel communication channel between healthcare providers and parents.
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Affiliation(s)
- Sungwon Yoon
- Health Services and Systems Research, Duke-NUS Medical School, Singapore.
| | - Hendra Goh
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Faculty of Dentistry, National University of Singapore, Singapore
| | - Chuan Ping Foo
- KK Research Centre, KK Women's and Children's Hospital, Singapore
| | - Martha I M Kao
- Department of Pediatrics, Neurology Service, KK Women's and Children's Hospital, Singapore
| | | | - Sze Ling Chan
- Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore
| | - Janardhan Krishnappa
- Department of Pediatrics, Neurology Service, KK Women's and Children's Hospital, Singapore
| | - Adeline Seow Fen Ngoh
- Department of Pediatrics, Neurology Service, KK Women's and Children's Hospital, Singapore
| | - Simon Robert Ling
- Department of Pediatrics, Neurology Service, KK Women's and Children's Hospital, Singapore
| | - Tong Hong Yeo
- Department of Pediatrics, Neurology Service, KK Women's and Children's Hospital, Singapore
| | - Derrick W S Chan
- KK Research Centre, KK Women's and Children's Hospital, Singapore; Department of Pediatrics, Neurology Service, KK Women's and Children's Hospital, Singapore
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16
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Patel AD, Debs A, Terry D, Parker W, Burch M, Luciano D, Patton L, Brubaker J, Chrisman J, Moellman K, Herbst J, Cohen DM. Decreasing Emergency Department Visits for Children With Epilepsy. Neurol Clin Pract 2021; 11:413-419. [PMID: 34840868 DOI: 10.1212/cpj.0000000000001109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 04/01/2021] [Indexed: 12/30/2022]
Abstract
Background and Objectives Epilepsy and seizures represent a frequent cause of emergency department (ED) visits for patients. By implementing quality improvement (QI) methodology, we planned to decrease ED visits for children and adolescents with epilepsy. Methods In 2016, a multidisciplinary team was created to implement QI methodology to address ED visits for patients with epilepsy. Based on previous successes, further ED visit reduction was deemed possible. Our aim statement was to decrease the number of ED visits, per 1000 established patients with epilepsy, from 13.03 to 11.6, by December 2019 and sustain for 1 year. Results We successfully decreased ED visits for seizure-related care in patients with epilepsy from 13.03% to 10.2% per 1,000 patients, which resulted in a centerline shift. Discussion Using QI methodology, we improved the outcome measure of decreasing ED visits for children with epilepsy. Implementations of these interventions can be considered at other institutions that may lead to similar results.
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Affiliation(s)
- Anup D Patel
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Andrea Debs
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Debbie Terry
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - William Parker
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Mary Burch
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Debra Luciano
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Lauren Patton
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Jena Brubaker
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Julie Chrisman
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Kathy Moellman
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - James Herbst
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
| | - Daniel M Cohen
- Division of Neurology (ADP, AD, DT, WP, MB, LP, JB, JC, KM), Center of Clinical Excellence (ADP), Department of Pharmacy (JH), and Division of Emergency Medicine (DMC), Nationwide Children's Hospital, Columbus, OH
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17
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Penovich P, Glauser T, Becker D, Patel AD, Sirven J, Long L, Stern J, Dixon-Salazar T, Carrazana E, Rabinowicz AL. Recommendations for development of acute seizure action plans (ASAPs) from an expert panel. Epilepsy Behav 2021; 123:108264. [PMID: 34482230 DOI: 10.1016/j.yebeh.2021.108264] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW Disease-related treatment action plans for acute exacerbations providing information that may be helpful for self-management for patients and caregivers are commonly used for chronic conditions such as asthma and diabetes. However, among patients with epilepsy, a review of the literature suggested that the majority did not have an action plan in place for acute seizure treatment. RECENT FINDINGS Currently, there is a lack of unified guidance on seizure action plans (SAPs) in the literature. In the authors' opinion, available formats have limitations for practical use and may not be easily customizable to individual patients, and they are not often designed to provide simple-to-follow steps for rapid immediate steps to determine and initiate appropriate treatment of seizure emergencies. Our group reviewed current examples of SAPs and provided guidance on the development of acute seizure action plans (ASAPs) designed to facilitate rapid, appropriate acute care in the community and to be as useful as possible for a wide range of care partners, including those with limited experience. SUMMARY This paper provides agreed upon expert opinion recommendations and considerations for goals, development process, types of content, and format for an ASAP.
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Affiliation(s)
| | - Tracy Glauser
- Comprehensive Epilepsy Center, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Danielle Becker
- Case Western Reserve University School of Medicine and MetroHealth System, Cleveland, OH, USA
| | - Anup D Patel
- Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Joseph Sirven
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Lucretia Long
- Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - John Stern
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Vidaurre J, Albert DVF, Parker W, Naprawa J, Mittlesteadt J, Idris AS, Patel AD. Improving time for administration of second-line antiseizure medications for children with generalized convulsive status epilepticus using quality improvement methodology. Epilepsia 2021; 62:2496-2504. [PMID: 34328222 DOI: 10.1111/epi.17026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Status epilepticus is a life-threatening neurological emergency. However, delay in median time to administration of second-line antiseizure medication exists. The aim of this quality improvement initiative was to decrease the average delay before fosphenytoin is administered for pediatric patients with generalized convulsive status epilepticus from 30 min (baseline data collected in 2013) to 15 min (50% reduction) by December 2015 and sustain this for 1 year. METHODS Our team conducted an analysis of baseline data for patients with continuous generalized convulsive status epilepticus who received fosphenytoin after receiving first-line benzodiazepine treatment. Using quality improvement methodology, areas for improvement were identified and specific interventions developed and implemented. A timeline of 15 min to initiate fosphenytoin administration after failure of first-line treatment was considered reasonable and achievable as a project aim. RESULTS A total of 199 patients were included in the dataset for the project. The database included patients aged 1 month and older. Ninety-eight percent of patients were between 1 month and 19 years of age. The gender distribution was even, with 54% of patients being White or Caucasian, 30% African American or Black, and 16% classified as "other." From January 2014 through December 2019, the average time before initiating fosphenytoin administration after failure of benzodiazepine therapy, for patients with generalized convulsive status epilepticus, decreased from 30 min (SD = 45.7) to 11.4 min (SD = 8.2, p = .043), thus reducing time to administration by 62%. SIGNIFICANCE Quality improvement methodology can be successfully applied to decrease administration time between first- and second-line antiseizure medications for status epilepticus.
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Affiliation(s)
- Jorge Vidaurre
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio, USA
| | - Dara V F Albert
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio, USA
| | - William Parker
- Quality Improvement Services at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jim Naprawa
- Section of Emergency Medicine, Benioff Children's Hospital, University of California, San Francisco, Oakland, California, USA
| | - Jackson Mittlesteadt
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio, USA
| | - Ali-Shan Idris
- Division of Neurology, Mount Carmel Health System, Columbus, Ohio, USA
| | - Anup D Patel
- Division of Neurology, Department of Pediatrics, Nationwide Children's Hospital/Ohio State University, Columbus, Ohio, USA
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Yaworski AM, Yager JY, Richer L, Mailo J, Rajapakse T, Kassiri J. Improved care and management of paediatric neurological patients evaluated at a paediatric Rapid Access Neurology clinic: A pilot study. J Paediatr Child Health 2021; 57:908-912. [PMID: 33460255 DOI: 10.1111/jpc.15352] [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: 08/13/2020] [Revised: 11/06/2020] [Accepted: 12/28/2020] [Indexed: 11/30/2022]
Abstract
AIM Referral wait times for paediatric neurological patients are increasing, leading to an increased burden on the emergency department (ED). The paediatric Rapid Access Neurology (pRAN) clinic was created for paediatric patients who are clinically stable, but require an urgent paediatric neurology consultation. The objectives were to evaluate the pathways of referral, accuracy of referring diagnoses, adherence to clinic appointments, impact of clinic visitation on ED visits and patient satisfaction. METHODS Data were collected from the pRAN clinic from March 2018 until April 2019. Information was obtained from patient charts including the referring and final diagnosis, management plan and the number of visits made to the ED before and after visiting the pRAN clinic. RESULTS Of the 256 referred patients, 91 met inclusion criteria. The most frequent referral diagnosis was a seizure. Referring physicians and pRAN clinic neurologists differed significantly in the level of diagnostic agreement for patients <2 years of age (P = 0.03; 95% confidence interval (CI) -0.294, 0.373). There was a significant reduction in visits to the ED made by patients 3 months after the pRAN appointment compared with before the visit (P < 0.001; 95% CI -0.9070, -0.4088). The majority of patients felt that the clinic had high value and were satisfied with their follow-up plan. CONCLUSION This pilot study showed that a pRAN clinic can improve the accuracy of neurological diagnoses and management, especially for children <2 years of age. In addition, pRAN clinic patients make fewer subsequent visits to the ED and express high satisfaction with their care.
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Affiliation(s)
- Amanda M Yaworski
- Division of Neurology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Jerome Y Yager
- Division of Neurology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Lawrence Richer
- Division of Neurology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Janette Mailo
- Division of Neurology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Thilinie Rajapakse
- Division of Neurology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Janani Kassiri
- Division of Neurology, Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta and Stollery Children's Hospital, Edmonton, Alberta, Canada
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20
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Seizure action plans in the pediatric population with epilepsy: Uptake, determinants, and parental interest in a mobile application. Epilepsy Behav 2021; 117:107860. [PMID: 33721835 DOI: 10.1016/j.yebeh.2021.107860] [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: 11/27/2020] [Revised: 01/31/2021] [Accepted: 02/12/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Status epilepticus (SE) is a common pediatric neurological emergency that requires timely treatment to minimize morbidity and mortality, yet administration of rescue medications is often delayed and underdosed. Seizure action plans (SAPs) outline the steps that should be taken by parents and caregivers in case of SE in order to optimize patient outcomes. Our study determined the uptake of SAPs in a pediatric population with epilepsy and assessed parental interest in a SAP mobile application. METHODS A survey was distributed to parents of patients with epilepsy aged 1 month to 19 years at British Columbia Children's Hospital. Following chart review, univariate and multivariate analyses were performed to identify variables that predict whether patients have SAPs. A systematic search of available mobile applications for epilepsy management was conducted. RESULTS Of 192 participants, 62% have SAPs. On univariate analysis, history of prior SE and male gender increased likelihood of SAP. On logistic regression, Nagelkerke R2 was 0.204 and our model correctly predicted 82% of patients with SAPs. 83% of parents were interested in a SAP mobile application. There are currently 40 mobile applications available for epilepsy management, but only 15% of respondents reported using them. CONCLUSIONS There is a need to increase the percentage of patients with epilepsy with SAPs, particularly in those at greater risk of SE. Most parents would find a SAP mobile application valuable in their child's epilepsy management. There is a gap between the high parental interest in mobile applications for epilepsy management and their current use of such applications.
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21
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Reducing Unnecessary Diagnostic Testing in Pediatric Syncope: A Quality Improvement Initiative. Pediatr Cardiol 2021; 42:942-950. [PMID: 33582873 PMCID: PMC8805737 DOI: 10.1007/s00246-021-02567-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 01/30/2021] [Indexed: 10/22/2022]
Abstract
Our aim was to reduce the frequency of unnecessary testing used by pediatric cardiologists in the evaluation of pediatric patients with syncope or pre-syncopal symptoms without negatively affecting patient outcomes. Guidelines for cardiac testing in pediatric patients with syncope were developed and disseminated to members of our pediatric cardiology division. Educational brochures and water bottles labeled with tips on preventing syncope were made available to families and providers in our clinics. Compliance to the guidelines was tracked and shared with providers. Segmented regression analysis was used to model cardiac testing utilization and guideline compliance by provider over time before and after the implementation of the guidelines. A pre-intervention cohort of 237 patients (June 2014-May 2015) was compared to 880 post-intervention patients (August 2015-June 2019). There was a significant decrease in the utilization of unnecessary tests [odds ratio (OR) 0.3; 95% confidence interval (CI) 0.14, 0.65; p = 0.002] after the intervention. Charges associated with patient evaluation were significantly lower in the post-intervention cohort (interquartile range $0, $1378 vs $0, $213; p = 0.005). Post-intervention visits to emergency departments within our system were significantly decreased, with no change in the incidence of cardiac arrest, hospitalization for syncope, or referral to pediatric electrophysiologists. We demonstrated a significant reduction in the use of unnecessary testing and associated charges by developing guidelines related to the evaluation of pediatric patients with syncope or pre-syncopal symptoms. There was no demonstrable negative impact on patient outcomes.
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22
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Min JY, Patel AD, Glynn P, Otgonsuren M, Harridas B, Grinspan ZM. Evaluation of a Care Management Program for Pediatric Epilepsy Patients. J Child Neurol 2021; 36:203-209. [PMID: 33095673 DOI: 10.1177/0883073820964165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To evaluate the impact of a pediatric epilepsy care management intervention on emergency department visits, hospitalizations, and seizure freedom. METHODS We conducted a prospective observational study at a single academic medical center. Children with epilepsy with high risk of frequent emergency department use were enrolled in the intervention from January through May 2015, which included a baseline visit and follow-up support from a care management team. Controls selected from the same institution received standard of care. Baseline and follow-up information were collected from electronic health records and surveys (Family Impact Scale, Pediatric Epilepsy Medication Self-Management Questionnaire). Propensity score-weighted logistic regression compared emergency department visits, unplanned hospitalizations, and 3-month seizure freedom after 1 year in the intervention vs control groups. RESULTS A total of 56 children were enrolled in the intervention and 359 received standard of care. The intervention group was younger and had greater use of health services at baseline. When comparing the intervention to standard of care after 1 year, we found no significant difference in the risk of any emergency department visit (adjusted odds ratio [OR] 2.2, 95% confidence interval [CI] 0.6-8.5) or seizure freedom (adjusted OR 2.5, 95% CI 0.3-21.5). However, the risk of unplanned hospital admissions remained higher in the intervention group (adjusted OR 23.1, 95% CI 5.1-104). CONCLUSION We did not find that children with epilepsy who received a care management intervention had less use of health services or better clinical outcomes after a year compared with controls. The study is limited by small sample size and nonrandomized study design.
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Affiliation(s)
- Jea Young Min
- Department of Population Health Sciences, 5922Weill Cornell Medicine, New York, NY, USA
| | - Anup D Patel
- 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Peter Glynn
- 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Munkhzul Otgonsuren
- Department of Population Health Sciences, 5922Weill Cornell Medicine, New York, NY, USA
| | - Babitha Harridas
- Jacobs School of Medicine and Biomedical Sciences, 12292University at Buffalo, Buffalo, NY, USA
| | - Zachary M Grinspan
- Department of Population Health Sciences, 5922Weill Cornell Medicine, New York, NY, USA.,Department of Pediatrics, 5922Weill Cornell Medicine, New York, NY, USA
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23
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Kobau R, Boring M, Zack MM, Croft JB. In 2016, Medicaid and Medicare paid about 65% of all inpatient hospitalization costs for all-age persons hospitalized with epilepsy as the principal diagnosis. Epilepsy Behav 2021; 114:107601. [PMID: 33298379 PMCID: PMC8514127 DOI: 10.1016/j.yebeh.2020.107601] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 10/24/2020] [Indexed: 01/06/2023]
Abstract
The purpose of this study was to examine both the distribution of payers for inpatient hospitalizations (all-ages) by principal diagnosis status (epilepsy versus nonepilepsy) and selected organizational- and community-level factors associated with hospitalizations using the Agency for Healthcare Research and Quality's (AHRQ) Healthcare Utilization Project 2016 National Inpatient Sample (NIS) database. We compared cases with epilepsy (any ICD-10CM diagnostic code beginning with "G40") as a principal diagnosis ("epilepsy discharges") versus cases without epilepsy as the principal diagnosis ("nonepilepsy discharges"). Accounting for the complex survey design, we examined how the principal payer source, median income for Zip Code, admission type, hospital location, teaching status, and hospital region varied by principal diagnosis status. For persons of all ages with epilepsy as a principal diagnosis, Medicaid and Medicare public insurance paid for about 65% of inpatient hospitalization costs. The percentage paid by Medicaid among epilepsy discharges (31.6%) significantly exceeded that among nonepilepsy discharges (23.1%). The percentage paid by Medicare among epilepsy discharges (33.9%) was significantly less than that among nonepilepsy discharges (39.7%), as was payment by private insurers (26.1% vs. 30.1%). Median Zip Code income, hospital and admission characteristics, and geographic region differed between hospitalizations with epilepsy versus those with a nonepilepsy discharge. These findings may be used to inform stakeholders' understanding of epilepsy care-related costs and factors associated with hospitalizations for improved interventions and programs.
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Affiliation(s)
- Rosemarie Kobau
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, 4770 Buford Highway NE, MS 107-6, Atlanta, GA 30341, USA.
| | - Michael Boring
- Starr and Associates, Epilepsy Program, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention (CDC), Mail Stop 107-6, 4770 Buford Hwy, 30341 GA, USA
| | - Matthew M. Zack
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, 4770 Buford Highway NE, MS 107-6, Atlanta, GA 30341, USA
| | - Janet B. Croft
- Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health, 4770 Buford Highway NE, MS 107-6, Atlanta, GA 30341, USA
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24
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Barcia Aguilar C, Sánchez Fernández I, Loddenkemper T. Status Epilepticus-Work-Up and Management in Children. Semin Neurol 2020; 40:661-674. [PMID: 33155182 DOI: 10.1055/s-0040-1719076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Status epilepticus (SE) is one of the most common neurological emergencies in children and has a mortality of 2 to 4%. Admissions for SE are very resource-consuming, especially in refractory and super-refractory SE. An increasing understanding of the pathophysiology of SE leaves room for improving SE treatment protocols, including medication choice and timing. Selecting the most efficacious medications and giving them in a timely manner may improve outcomes. Benzodiazepines are commonly used as first line and they can be used in the prehospital setting, where most SE episodes begin. The diagnostic work-up should start simultaneously to initial treatment, or as soon as possible, to detect potentially treatable causes of SE. Although most etiologies are recognized after the first evaluation, the detection of more unusual causes may become challenging in selected cases. SE is a life-threatening medical emergency in which prompt and efficacious treatment may improve outcomes. We provide a summary of existing evidence to guide clinical decisions regarding the work-up and treatment of SE in pediatric patients.
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Affiliation(s)
- Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Child Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Child Neurology, Hospital Sant Joan de Déu, University of Barcelona, Spain
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Patel AD, Herbst J, Gibson A, Karn M, Terry D, Debs A, Yarosz S, Parker W, Cohen DM. Using quality improvement to implement the CNS/AAN quality measure on rescue medication for seizures. Epilepsia 2020; 61:2712-2719. [PMID: 33063879 DOI: 10.1111/epi.16713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVE A multidisciplinary quality improvement (QI) team was established to conduct analysis of data for prescribed seizure rescue medication doses from January 2013 to December 2015 to identify and improve inappropriately low dose prescriptions. The QI team identified areas of focus for improvement opportunities and developed the project objective based on the 2017 American Academy of Neurology (AAN) and Child Neurology Society (CNS) quality measure. METHODS Within a freestanding children's hospital, the QI team developed key drivers and implemented interventions, such as the midazolam prefilled syringe program with use of standardized dosing, electronic chart tools, monthly pharmacy review of all underdosed prescriptions, and provider and nursing education. The team created an automated monthly report to monitor prescribed seizure rescue medication dosing compliance. The year 2015 was used as the preliminary data baseline period with an average noncompliance rate of 3.5%. RESULTS From January 2016 to December 2019, the team has decreased and sustained the noncompliance rate to an average of 0.38%. The data for the project included 12,975 seizure rescue medication prescribed by a neurology provider from January 2015 to December 2019. Compliance with properly dosed diazepam orders continues to be the largest area of opportunity. The data demonstrated a centerline shift in January 2019, moving the baseline average of 7.2% noncompliance to the current average rate of 0.22%. In comparison, underdosed midazolam orders occurred at an average rate of 0.037% in the same timeframe. SIGNIFICANCE Using quality improvement methodologies, the team successfully and substantially decreased provider prescribed and signed underdosed rescue medication orders by an average of 89%. This QI project demonstrates successful implementation and improvement addressing the AAN/CNS quality measure of proper rescue seizure treatment dosing.
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Affiliation(s)
- Anup D Patel
- Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - James Herbst
- Department of Pharmacology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Annika Gibson
- Department of IS, Nationwide Children's Hospital, Columbus, OH, USA
| | - Mary Karn
- Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Debbie Terry
- Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Andrea Debs
- Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Shannon Yarosz
- Department of Pharmacology, Nationwide Children's Hospital, Columbus, OH, USA
| | - William Parker
- Department of Neurology, Nationwide Children's Hospital, Columbus, OH, USA
| | - Daniel M Cohen
- Department of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH, USA
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26
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Sánchez Fernández I, Gaínza-Lein M, Barcia Aguilar C, Amengual-Gual M, Loddenkemper T. The burden of decisional uncertainty in the treatment of status epilepticus. Epilepsia 2020; 61:2150-2162. [PMID: 32959410 DOI: 10.1111/epi.16646] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/21/2020] [Accepted: 07/21/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Treatments for convulsive status epilepticus (SE) have a wide range of effectiveness. The estimated effectiveness of non-intravenous benzodiazepines (non-IV BZDs) ranges from approximately 70% to 90% and the estimated effectiveness of non-benzodiazepine antiseizure medications (non-BZD ASMs) ranges from approximately 50% to 80%. This study aimed to quantify the clinical and economic burden of decisional uncertainty in the treatment of SE. METHODS We performed a decision analysis that evaluates how decisional uncertainty on treatment choices for SE impacts hospital admissions, intensive care unit (ICU) admissions, and costs in the United States. We evaluated treatment effectiveness based on the available literature. RESULTS Use of a non-IV BZD with high estimated effectiveness, like intranasal midazolam, rather than one with low estimated effectiveness, like rectal diazepam, would result in a median (p25 -p75 ) reduction in hospital admissions from 6 (3.9-8.8) to 1.1 (0.7-1.8) per 100 cases and associated cost reductions of $638 ($289-$1064) per pediatric patient and $1107 ($972-$1281) per adult patient. For BZD-resistant SE, use of a non-BZD ASM with high estimated effectiveness, like phenobarbital, rather than one with low estimated effectiveness, like phenytoin/fosphenytoin, would result in a reduction in ICU admissions from 9.1 (7.3-11.2) to 3.9 (2.6-5.5) per 100 cases and associated cost reduction of $1261 ($445-$2223) per pediatric patient and $319 ($-93-$806) per adult patient. Sensitivity analyses showed that relatively minor improvements in effectiveness may lead to substantial reductions in downstream hospital admissions, ICU admissions, and costs. SIGNIFICANCE Decreasing decisional uncertainty and using the most effective treatments for SE may substantially decrease hospital admissions, ICU admissions, and costs.
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Affiliation(s)
- Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - Marina Gaínza-Lein
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Instituto de Pediatría, Facultad de Medicina, Universidad Austral de Chile, Valdivia, Chile.,Servicio de Neuropsiquiatría Infantil. Hospital Clínico San Borja Arriarán, Universidad de Chile, Santiago, Chile
| | - Cristina Barcia Aguilar
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, Hospital Universitario La Paz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric Neurology Unit, Department of Pediatrics, Hospital Universitari Son Espases, Universitat de les Illes Balears, Palma, Spain
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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27
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Amengual-Gual M, Sánchez Fernández I, Vasquez A, Loddenkemper T. Retrospective observational study on hospital readmission for status epilepticus in the United States over 2016. Epilepsia 2020; 61:1386-1396. [PMID: 32683696 DOI: 10.1111/epi.16586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 05/29/2020] [Accepted: 05/29/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Describe hospital readmission for status epilepticus (SE) in the United States, and study potential risk factors for readmission. METHODS This is a retrospective observational study using the Healthcare Cost and Utilization Project's 2016 Nationwide Readmissions Database. We studied patients of all ages admitted to the hospital due to SE. RESULTS We included 32 327 patients admitted for SE in 2016. 8.4% of these patients were readmitted for SE at least one more time within 2016 (cross-sectional analysis). The incidence rate was 18 readmissions for SE per 1000 patient-months. Among the survivors of the index admission for SE who had at least 6 months of follow-up within this database (16 043 patients), the cumulative probability of having a readmission for SE at 1, 3, and 6 months from the index admission was approximately 3.5%, 7.5%, and 11%, respectively (time-to-event analysis). Patients with refractory epilepsy were more likely to have a readmission for SE compared to patients without refractory epilepsy (hazard ratio [HR] 1.49, 95% confidence interval [CI] 1.23-1.82, adjusted P =.0006), and pediatric patients were more likely to have a readmission for SE compared to adult patients (HR 1.53, 95% CI 1.26-1.87, adjusted P = .0003) during 6-month follow-up. SIGNIFICANCE Hospital readmissions for SE in the United States are frequent. Independent factors associated with readmission in this database were refractory epilepsy and pediatric age.
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Affiliation(s)
- Marta Amengual-Gual
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Pediatric Neurology Unit, Department of Pediatrics, Son Espases University Hospital, University of the Balearic Islands, Palma, Spain
| | - Iván Sánchez Fernández
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Child Neurology, Hospital Sant Joan de Déu, Universidad de Barcelona, Barcelona, Spain
| | - Alejandra Vasquez
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.,Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Tobias Loddenkemper
- Division of Epilepsy and Clinical Neurophysiology, Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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28
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Shah M, Douglas J, Carey R, Daftari M, Smink T, Paisley A, Cannady S, Newman J, Rajasekaran K. Reducing ER Visits and Readmissions after Head and Neck Surgery Through a Phone-based Quality Improvement Program. Ann Otol Rhinol Laryngol 2020; 130:24-31. [DOI: 10.1177/0003489420937044] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objective: Evaluate the impact of a patient phone calls and virtual wound checks within 72 hours of discharge on reducing emergency room (ER) visits and readmissions. Methods: Single arm trial with comparison to historical control data of patients undergoing multi subsite head and neck cancer operations or laryngectomy between July 2017 and June 2018 at a tertiary academic medical center. Patients were contacted within 72 hours of hospital discharge. As a supplement to the call, patients were given the opportunity to video conference with and/or send pictures to the provider with additional questions via a designated wound care phone. Results: Ninety-one patients met inclusion criteria, of whom 83 (91.2%) were contacted. Six patients (7%) were readmitted, of whom three had not been able to be reached. The patients who had been unable to be contacted were readmitted for dysphagia (2), and a urinary tract infection (1). The contacted patients were advised to go the ER during the call for concerns for postoperative bleeding (2) and gastrointestinal bleeding (1). Twenty-five patients (30%) utilized the wound care phone. 18 patients (21.7%) reported that the phone call survey prevented them from going to the ER. When compared to the prior year, there was as statistically significant decrease in ER visits ( P < .05), and no change in readmissions. Conclusions: Implementation of a phone call in the early postoperative period has the potential to decrease unnecessary ER visits and enhance patient satisfaction. This may decrease strain on the health care system and improve patient care. Level of Evidence: 4
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Affiliation(s)
- Mitali Shah
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Jennifer Douglas
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan Carey
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Manvav Daftari
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Teresa Smink
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Allison Paisley
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Steven Cannady
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Jason Newman
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, University of Pennsylvania, Philadelphia, PA, USA
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29
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Albert DVF, Moreland JJ, Salvator A, Moore-Clingenpeel M, Haridas B, Cole JW, Glynn P, Fults M, Dawson MZ, Moreland P, Patel AD. Seizure Action Plans for Pediatric Patients With Epilepsy: A Randomized Controlled Trial. J Child Neurol 2019; 34:666-673. [PMID: 31156013 DOI: 10.1177/0883073819846810] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Seizure action plans help patients and caregivers better self-manage their epilepsy. We hypothesized that providing pediatric patients and their caregivers with a seizure action plan would reduce unplanned health care utilization and decrease the impact of epilepsy. METHODS We developed a seizure action plan for use in pediatric epilepsy patients. A prospective cohort was randomly assigned to receive a seizure action plan in addition to standard epilepsy care or to standard epilepsy care alone. All caregivers were surveyed using the Modified Impact on Families (MIF) questionnaire at enrollment, 3 months, and 12 months. Health care utilization measures and Modified Impact on Families questionnaire scores were compared between the 2 groups. RESULTS Fifty-four patients received a seizure action plan and standard care, whereas 48 received standard care alone. The groups had similar demographics. There was a significantly higher proportion of overall clinic appointment no shows in the standard care group vs the seizure action plan group (P = .04); however, other significant differences in health care utilization were not found. Among patients with low seizure frequency (12 or fewer seizures per year), Seizure comfort scores on the Modified Impact on Families questionnaire were significantly higher at 12 months among the seizure action plan group compared to the standard care group. SIGNIFICANCE Caregivers for patients with epilepsy receiving a seizure action plan were more comfortable regarding seizure care and missed fewer appointments. However, differences in health care utilization were not present. The seizure action plan appears to have more impact in patients who experience lower seizure frequencies. Further studies evaluating the impact as well as assessing caregivers' perceptions of the seizure action plan using a larger sample are needed.
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Affiliation(s)
- Dara V F Albert
- 1 Nationwide Children's Hospital/Ohio State University, Department of Pediatrics, Division of Child Neurology, Columbus, OH, USA
| | | | - Ann Salvator
- 2 Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | | | - Babitha Haridas
- 3 Oshei Children's Hospital/University at Buffalo, Department of Pediatric Neurology, Buffalo, NY, USA
| | - Justin W Cole
- 4 Cedarville University School of Pharmacy, Department of Pharmacy Practice, Cedarville, OH, USA
| | - Peter Glynn
- 2 Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Marci Fults
- 1 Nationwide Children's Hospital/Ohio State University, Department of Pediatrics, Division of Child Neurology, Columbus, OH, USA
| | | | - Patty Moreland
- 6 Nationwide Children's Hospital, Department of Information Services, Columbus, OH, USA
| | - Anup D Patel
- 1 Nationwide Children's Hospital/Ohio State University, Department of Pediatrics, Division of Child Neurology, Columbus, OH, USA
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30
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Lee J, Israel E, Weinstein H, Kinane TB, Pasternack M, Linov P, Kaafarani HMA, Greenspan P, Rao SK. Using Physician-Level Emergency Department Utilization Reports to Address Avoidable Visits by Patients Managed by Pediatric Specialists. Hosp Pediatr 2019; 7:686-691. [PMID: 29055023 DOI: 10.1542/hpeds.2017-0054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Emergency department (ED) utilization is a major driver of cost. Specialist physicians have an important role in addressing ED utilization, especially at tertiary medical centers that treat highly specialized patients. We analyzed if reporting of ED utilization to pediatric specialist physicians can decrease ED visits. METHODS Physicians within pediatric neurology, hematology and oncology, infectious diseases, and pulmonary divisions received their ED use reports. By using control charts, we examined if this intervention decreased the rate of ED utilization. RESULTS Overall, for the 4 divisions, specialty-related ED utilization decreased significantly during all hours, weekdays, and office hours. This was in the setting of ED utilization increasing for all diagnoses ED visits. Pediatric ED volume did not change during the study period. CONCLUSIONS Physician-level reporting of ED utilization was associated with a reduction in ED use by patients managed by our pediatric specialists.
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Affiliation(s)
- Jarone Lee
- Departments of Emergency Medicine, .,Massachusetts General Physician Organization, Boston, Massachusetts.,Surgery
| | - Esther Israel
- Massachusetts General Physician Organization, Boston, Massachusetts.,Pediatrics, and
| | - Howard Weinstein
- Massachusetts General Physician Organization, Boston, Massachusetts.,Pediatrics, and
| | - T Bernard Kinane
- Massachusetts General Physician Organization, Boston, Massachusetts.,Pediatrics, and
| | - Mark Pasternack
- Massachusetts General Physician Organization, Boston, Massachusetts.,Pediatrics, and
| | - Pamela Linov
- Massachusetts General Physician Organization, Boston, Massachusetts
| | | | | | - Sandhya K Rao
- Pediatrics, and.,Medicine, Massachusetts General Hospital, Boston, Massachusetts; and
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31
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Dayal P, Chang CH, Benko WS, Pollock BH, Crossen SS, Kissee J, Ulmer AM, Hoch JS, Warner L, Marcin JP. Hospital Utilization Among Rural Children Served by Pediatric Neurology Telemedicine Clinics. JAMA Netw Open 2019; 2:e199364. [PMID: 31418803 PMCID: PMC6704740 DOI: 10.1001/jamanetworkopen.2019.9364] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Accepted: 06/26/2019] [Indexed: 11/14/2022] Open
Abstract
Importance Telemedicine is increasingly used to provide outpatient pediatric neurology consultations in underserved communities. Although telemedicine clinics have been shown to improve access, little is known about how they alter patients' utilization of hospital services. Objective To evaluate the association between access to telemedicine clinics and hospital utilization among underserved children with neurologic conditions. Design, Setting, and Participants This retrospective cross-sectional study included 4169 patients who received outpatient care from pediatric neurologists affiliated with an academic children's hospital in California between January 1, 2009, and July 31, 2017, either in person or using telemedicine. Exposures Consultation modality (telemedicine or in person) in the outpatient neurology clinics. Main Outcomes and Measures Demographic and clinical variables were abstracted from the hospital's electronic medical records. The association between the modality of outpatient neurology care and patients' utilization of the emergency department and hospitalizations was evaluated. Both all-cause and neurologic condition-related hospital utilization were analyzed using multivariable negative binomial regression in overall and matched samples. Results The telemedicine cohort comprised 378 patients (211 [55.8%] male), and the in-person cohort comprised 3791 patients (2090 [55.1%] male). The mean (SD) age at the first encounter was 7.4 (5.4) years for the telemedicine cohort and 7.8 (5.1) years for the in-person cohort. The telemedicine cohort was more likely than the in-person cohort to have nonprivate insurance (public insurance, self-pay, or uninsured), lower education, and lower household income. The rates of all-cause and neurologic hospital encounters were lower among children who received pediatric neurology consultations over telemedicine compared with children who received care in the in-person clinics (5.7 [95% CI, 3.5-8.0] vs 20.1 [95% CI, 18.1-22.1] per 100 patient-years and 3.7 [95% CI, 2.0-5.3] vs 8.9 [95% CI, 7.8-10.0] per 100 patient-years, respectively; P < .001). Even after adjusting for demographic and clinical factors, the telemedicine cohort had a lower risk of hospital encounters (emergency department visits and admissions) with an adjusted incidence rate ratio of 0.57 (95% CI, 0.38-0.88) for all-cause encounters and an adjusted incidence rate ratio of 0.60 (95% CI, 0.36-0.99) for neurologic encounters. After matching on travel time to the neurology clinic, the adjusted incidence rate ratio was 0.19 (95% CI, 0.04-0.83) for all-cause admissions and 0.14 (95% CI, 0.02-0.82) for neurologic admissions. Conclusions and Relevance Pediatric neurology care through real-time, audiovisual telemedicine consultations was associated with lower hospital utilization compared with in-person consultations, suggesting that high-cost hospital encounters can be prevented by improving subspecialty access.
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Affiliation(s)
- Parul Dayal
- Department of Pediatrics, University of California Davis Health, Sacramento
- Now with Genentech Inc, South San Francisco, California
| | - Celia H. Chang
- Department of Neurology, University of California Davis Health, Sacramento
| | - William S. Benko
- Department of Neurology, University of California Davis Health, Sacramento
| | - Brad H. Pollock
- Department of Public Health Sciences, University of California Davis Health, Sacramento
| | | | - Jamie Kissee
- Department of Pediatrics, University of California Davis Health, Sacramento
| | - Aaron M. Ulmer
- Center for Health and Technology, University of California Davis Health, Sacramento
| | - Jeffrey S. Hoch
- Department of Public Health Sciences, University of California Davis Health, Sacramento
- Center for Healthcare Policy and Research, University of California Davis Health, Sacramento
| | | | - James P. Marcin
- Department of Pediatrics, University of California Davis Health, Sacramento
- Center for Health and Technology, University of California Davis Health, Sacramento
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Aaronson EL, Kim J, Hard GA, Yun BJ, Kaafarani HMA, Rao SK, Weilburg JB, Lee J. Emergency department visits by patients with an internal medicine specialist: understanding the role of specialists in reducing ED crowding. Intern Emerg Med 2019; 14:777-782. [PMID: 30796698 DOI: 10.1007/s11739-019-02051-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Accepted: 02/11/2019] [Indexed: 10/27/2022]
Abstract
As emergency department (ED) crowding continues to worsen, many visits are at academic referral hospitals. As a result, engaging specialty services will be essential to decompressing the ED. To do this, it will be important to understand which specialties to focus interventions on for the greatest impact. To characterize the ED utilization of non-surgical adult patients with an ambulatory specialist who were seen and discharged from the ED. Retrospective cohort study of all consecutive patients currently under the care from a specialist presenting to an urban, university affiliated hospital between 01 January 2015 and 31 December 2016. The identification of ED visits attributable to specialists was based on the primary diagnosis of ED visits and the frequency of visit with specialists within a given timeframe. Only patients who were discharged directly from the ED were included in the analysis. There were 29,853 ED visits by patients currently under the care of a specialist during the study period. 17.76% of these visits were related to the medical specialty of the specialist. Of these visits, 41.73% occurred during office hours, and 24.81% occurred during weekends. The specialties with the largest proportion of ED visits related to their specialty was cardiology, gastroenterology, and pulmonary, respectively. Nearly 18% of all patients that have a specialist and are treated and discharged from the ED present with a diagnosis related to their specialist's practice. This may indicate that there is a role for specialty service to play in decreasing some ED utilization that may be appropriate for the out-patient clinical setting. By focusing attention on specific specialties and interventions targeted during office hours, there may be an opportunity to decrease ED utilization.
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Affiliation(s)
- Emily L Aaronson
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, MA, USA
| | - Jungyeon Kim
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Gregory A Hard
- Clinical Trials Network and Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham M A Kaafarani
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
| | - Sandhya K Rao
- Department of Primary Care, Massachusetts General Hospital, Boston, MA, USA
| | - Jeffery B Weilburg
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Jarone Lee
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Department of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
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Dayal P, Chang CH, Benko WS, Ulmer AM, Crossen SS, Pollock BH, Hoch JS, Kissee JL, Warner L, Marcin JP. Appointment completion in pediatric neurology telemedicine clinics serving underserved patients. Neurol Clin Pract 2019; 9:314-321. [PMID: 31583186 DOI: 10.1212/cpj.0000000000000649] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 03/04/2019] [Indexed: 11/15/2022]
Abstract
Background To determine whether telemedicine improves access to outpatient neurology care for underserved patients, we compared appointment completion between urban, in-person clinics and telemedicine clinics held in rural and underserved communities where neurology consultations are provided remotely. Methods In this retrospective study, we identified patients scheduled for outpatient care from UCDH pediatric neurologists between January 1, 2009, and July 31, 2017, in person and by telemedicine. Demographic and clinical variables were abstracted from electronic medical records. We evaluated the association between consultation modality and visit completion in overall and matched samples using hierarchical multivariable logistic regression. Results We analyzed 13,311 in-person appointments by 3,831 patients and 1,158 telemedicine appointments by 381 patients. The average travel time to the site of care was 45.8 ± 52.1 minutes for the in-person cohort and 22.3 ± 22.7 minutes for the telemedicine cohort. Telemedicine sites were located at an average travel time of 217.1 ± 114.8 minutes from UCDH. Telemedicine patients were more likely to have nonprivate insurance, lower education, and lower household income. They had different diagnoses and fewer complex chronic conditions. Telemedicine visits were more likely to be completed than either "cancelled" or missed ("no show") compared with in-person visits (OR 1.57, 95% CI: 1.34-1.83; OR 1.66, 95% CI: 1.31-2.10 matched on travel time to the site of care; OR 2.22, 95% CI: 1.66-2.98 matched on travel time to UCDH). Conclusions The use of telemedicine for outpatient pediatric neurology visits has high odds of completion and can serve as an equal adjunct to in-person clinic visits.
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Affiliation(s)
- Parul Dayal
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - Celia H Chang
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - William S Benko
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - Aaron M Ulmer
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - Stephanie S Crossen
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - Brad H Pollock
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - Jeffrey S Hoch
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - Jamie L Kissee
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - Leslie Warner
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
| | - James P Marcin
- Department of Pediatrics (PD, SSC, JLK, JPM) and Department of Neurology (CHC, WSB), University of California Davis Health; Center for Health and Technology (AMU, JPM), University of California Davis Health; Department of Public Health Sciences (BHP, JSH), University of California Davis Health; Center for Healthcare Policy and Research (JSH), University of California Davis Health, Sacramento; and Shasta Community Health Center (LW), Redding, CA
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'I hate wasting the hospital's time': Experiences of emergency department admissions of Australian people with epilepsy. Epilepsy Behav 2019; 90:228-232. [PMID: 30573339 DOI: 10.1016/j.yebeh.2018.11.018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 11/18/2018] [Accepted: 11/18/2018] [Indexed: 11/20/2022]
Abstract
AIM This paper investigates the reasons and extent of hospital emergency department (ED) attendance by people with epilepsy in Wave 4 of The Australian Longitudinal Survey 2016-17. METHOD Wave 4 had 393 respondents who completed the survey, which included questions relating to their use of hospital and healthcare services. Of these, 121 (31%; 82 females) reported one or more admissions to the ED within the previous 12 months. We conducted a mixed methods analysis - using quantitative measures to explore the type and number of admissions, factors relating to increased admissions, and a qualitative approach to explore respondent experiences of their admissions. RESULTS Over half of the admissions reported were seizure-related, including injuries occurring as a result of seizures. More than 15% of respondents had more than four ED visits during the preceding 12 months of the survey. Those who had experienced seizures within the previous 12 months, irrespective of frequency, were more likely to have attended the ED compared with those who had not experienced a recent seizure. Self-reported income was another major factor in ED use. Experiences of hospitalization demonstrated frustration at being taken to the ED, loss of autonomy, and experiences of inappropriate care due to poor understanding of epilepsy. Some respondents did not want to waste the ED time as they felt that a rest was all they needed following a seizure. DISCUSSION The rates of hospitalization for seizure-related reasons are in line with the findings of other epilepsy-related studies, as is the increased hospitalization rate of those from less well-off backgrounds. This study provided a valuable picture of the opinions and attitudes of people with epilepsy towards their healthcare services. CONCLUSION While this is an analysis of a small cohort, the consistency of reported experiences suggests that ED is not always felt to be appropriate following a seizure, and misunderstanding around the appropriate treatment of epilepsy continues in healthcare services.
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Towards acute pediatric status epilepticus intervention teams: Do we need “Seizure Codes”? Seizure 2018; 58:133-140. [DOI: 10.1016/j.seizure.2018.04.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/15/2018] [Accepted: 04/12/2018] [Indexed: 12/28/2022] Open
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Relationship between office-based provider visits and emergency department encounters among publicly-insured adults with epilepsy. Epilepsy Behav 2018; 80:235-239. [PMID: 29429907 DOI: 10.1016/j.yebeh.2018.01.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 01/19/2018] [Accepted: 01/23/2018] [Indexed: 01/12/2023]
Abstract
INTRODUCTION The proportion of adults with epilepsy using the emergency department (ED) is high. Among this patient population, increased frequency of office-based provider visits may be associated with lesser frequency of ED encounters, and key patient features may be linked to more ED encounters. METHODS We analyzed the Medical Expenditure Panel Survey Household Component (MEPS-HC) dataset for years 2003-2014, which represents a weighted sample of 842,249 publicly-insured US adults aged ≥18years. The Hurdle Poisson model that accommodates excess zeros was used to estimate the association between office-based and ED visits. RESULTS Annual mean ED and office-based visits for publicly-insured adults with epilepsy were 0.70 and 10.8 respectively. Probability of at least one ED visit was 0.4% higher for every unit of office-based visit. Individuals in the high income category were less likely to visit the ED at least once while women with epilepsy had a higher likelihood of visiting the ED at least once. Among those who visited the ED at least once, there was a 0.3% higher likelihood of visiting the ED for every unit of office-based visit. Among individuals who visited the ED at least once, being aged 45-64years, residing in the West, and the year 2011/14 were associated with higher ED visits. CONCLUSION In this representative sample of publicly-insured adults with epilepsy, higher frequency of office visits was not associated with lower ED utilization, which may be due to underlying greater disease severity or propensity for more treatment complications.
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Ostendorf AP, Gedela S. Effect of Epilepsy on Families, Communities, and Society. Semin Pediatr Neurol 2017; 24:340-347. [PMID: 29249514 DOI: 10.1016/j.spen.2017.10.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The effect of epilepsy extends beyond those with the diagnosis and impacts families, communities and society. Caregiver and sibling quality of life is often negatively affected by frequent seizures, comorbid behavioral and sleep disorders and stigma surrounding the diagnosis. Furthermore, the negative effects can be magnified by individual coping styles and resources available to families of those with epilepsy. Beyond the family and immediate caregivers, epilepsy affects local communities by drawing additional resources from education systems. The direct costs of caring for an individual with epilepsy and the indirect costs associated with decreased productivity place financial strain on individuals and health care systems throughout the world. This review details factors affecting family and caregiver quality of life and provides several approaches through which health care providers may address these concerns. Furthermore, we examine the financial effect of epilepsy on society and review emerging strategies to lessen health care use for individuals with epilepsy.
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Affiliation(s)
- Adam P Ostendorf
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH.
| | - Satyanarayana Gedela
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
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Bellon ML, Barton C, McCaffrey N, Parker D, Hutchinson C. Seizure-related hospital admissions, readmissions and costs: Comparisons with asthma and diabetes in South Australia. Seizure 2017. [PMID: 28624716 DOI: 10.1016/j.seizure.2017.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE Seizures are listed as an Ambulatory Care Sensitive Condition (ACSC), where, in some cases, hospitalisation may be avoided with appropriate preventative and early management in primary care. We examined the frequencies, trends and financial costs of first and subsequent seizure-related hospital admissions in the adult and paediatric populations, with comparisons to bronchitis/asthma and diabetes admissions in South Australia between 2012 and 2014. METHODS De-identified hospital separation data from five major public hospitals in metropolitan South Australia were analysed to determine the number of children and adults admitted for the following Australian Refined Diagnosis Related Groups: seizure related conditions; bronchitis/asthma; and diabetes. Additional data included length of hospital stay and type of admission. Demographic data were analysed to identify whether social determinants influence admission, and a macro costing approach was then applied to calculate the financial costs to the Health Care System. RESULTS The rate of total seizure hospitalizations was 649 per 100,000; lower than bronchitis/asthma (751/100,000), yet higher than diabetes (500/100,000). The highest proportions of subsequent separations were recorded by children with seizures regardless of complexity (47% +CSCC; 17% -CSCC) compared with asthma (11% +CSCC; 14% -CSCC) or diabetes (14% +CSCC; 13% -CSCC), and by adults with seizures with catastrophic or severe complications/comorbidity (25%), compared with diabetes (22%) or asthma (14%). The mean cost per separation in both children and adults was highest for diabetes (AU$4438/$7656), followed by seizures (AU$2408/$5691) and asthma (AU$2084/$3295). CONCLUSIONS Following the lead of well-developed and resourced health promotion initiatives in asthma and diabetes, appropriate primary care, community education and seizure management services (including seizure clinics) should be targeted in an effort to reduce seizure related hospitalisations which may be avoidable, minimise costs to the health budget, and maximise health care quality.
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Affiliation(s)
- Michelle L Bellon
- School of Health Sciences, Flinders University, Adelaide, Australia.
| | | | - Nikki McCaffrey
- School of Health & Social Development, Deakin University, Victoria, Australia.
| | - Denise Parker
- School of Health Sciences, Flinders University, Adelaide, Australia.
| | - Claire Hutchinson
- School of Health Sciences, Flinders University, Adelaide, Australia.
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