The worldwide epilepsy treatment gap: A systematic review and recommendations for revised definitions - A report from the ILAE Epidemiology Commission

OBJECTIVE

In order to more appropriately apply and understand the "epilepsy treatment gap" (ETG) concept in current health systems, revised conceptual and operational definitions of ETG are timely and necessary. This article therefore systematically reviews worldwide studies of the ETG, distinguishing high-, middle-, and low-income regions, and provides recommendations for an updated International League Against Epilepsy (ILAE) definition of ETG.

METHODS

A systematic review of the ETG was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. The search was conducted from January 1990 to July 2019, in the online databases of Ovid MEDLINE and Embase. Identified abstracts were reviewed in duplicate and data independently extracted using a standard proforma. Data describing treatment gap information including both diagnostic and therapeutic aspects of access to epilepsy treatment were recorded. Descriptive statistics are presented.

RESULTS

The treatment gap reported in the 45 distinctive populations represented 33 countries. Treatment gap definitions varied widely. The reported ETGs ranged broadly from 5.6% in Norway to 100% in parts of Tibet, Togo, and Uganda. The wide range of reported ETGs was multifactorial in origin including true differences in the availability and utilization of health care among study populations, variations in operational definitions of the epilepsy treatment gap, and methodological differences in sampling and identifying representative epilepsy cases in populations. Significance and recommendations For the ETG to be a useful metric to compare levels of unmet epilepsy care across different countries and regions, a standardized definition must be adapted, recognizing some of the limitations of the current definitions. Our proposed definition takes into account the lack of effective health care insurance, the diagnostic gap, the therapeutic gap, quality-of-care, and other unmet health care needs."

Antiepileptic Drug Treatment Patterns in Women of Childbearing Age With Epilepsy

Importance

Limited population-based data are available on antiepileptic drug (AED) treatment patterns in women of childbearing age with epilepsy; the current population risk is not clear.

Objectives

To examine the AED treatment patterns and identify differences in use of valproate sodium and topiramate by comorbidities among women of childbearing age with epilepsy.

Design, Setting, and Participants

A retrospective cohort study used a nationwide commercial database and supplemental Medicare as well as Medicaid insurance claims data to identify 46 767 women with epilepsy aged 15 to 44 years. The eligible study cohort was enrolled between January 1, 2009, and December 31, 2013. Data analysis was conducted from January 1, 2017, to February 22, 2018.

Exposures

Cases required an International Classification of Diseases, Ninth Revision, Clinical Modification-coded epilepsy diagnosis with continuous medical and pharmacy enrollment. Incident cases required a baseline of 2 or more years without an epilepsy diagnosis or AED prescription before the index date. For both incident and prevalent cases, focal and generalized epilepsy cohorts were matched by age, payer type, and enrollment period and then compared.

Main Outcomes and Measures

Antiepileptic drug treatment pattern according to seizure type and comorbidities.

Results

Of the 46 767 patients identified, there were 8003 incident cases (mean [SD] age, 27.3 [9.4] years) and 38 764 prevalent cases (mean [SD] age, 29.7 [9.0] years). Among 3219 women in the incident epilepsy group who received AEDs for 90 days or more, 3173 (98.6%) received monotherapy as first-line treatment; among 28 239 treated prevalent cases, 18 987 (67.2%) received monotherapy. In 3544 (44.3%) incident cases and 9480 (24.5%) prevalent cases, AED treatment was not documented during 180 days or more of follow-up after diagnosis. Valproate (incident: 35 [5.81%]; prevalent: 514 [13.1%]) and phenytoin (incident: 33 [5.48%]; prevalent: 178 [4.53%]) were more commonly used for generalized epilepsy and oxcarbazepine (incident: 53 [8.03%]; prevalent: 386 [9.89%]) was more often used for focal epilepsy. Levetiracetam (incident: focal, 267 [40.5%]; generalized, 271 [45.0%]; prevalent: focal, 794 [20.3%]; generalized, 871 [22.2%]), lamotrigine (incident: focal, 123 [18.6%]; generalized, 106 [17.6%]; prevalent: focal, 968 [24.8%]; generalized, 871 [22.2%]), and topiramate (incident: focal, 102 [15.5%]; generalized, 64 [10.6%]; prevalent: focal, 499 [12.8%]; generalized, 470 [12.0%]) were leading AEDs prescribed for both focal and generalized epilepsy. Valproate was more commonly prescribed for women with comorbid headache or migraine (incident: 53 of 1251 [4.2%]; prevalent: 839 of 8046 [10.4%]), mood disorder (incident: 63 of 860 [7.3%]; prevalent: 1110 of 6995 [15.9%]), and anxiety and dissociative disorders (incident: 57 of 881 [6.5%]; prevalent: 798 of 5912 [13.5%]). Topiramate was more likely prescribed for those with comorbid headache or migraine (incident: 335 of 1251 [26.8%]; prevalent: 2322 of 8046 [28.9%]).

Conclusions and Relevance

Many women appear to be treated with valproate and topiramate despite known teratogenicity risks. Comorbidities may affect selecting certain AEDs despite their teratogenicity risks.

New-onset lesional and nonlesional epilepsy in the US population: Patient characteristics and patterns of antiepileptic drug use

PURPOSE

Describe treatment patterns in patients from the United States with new-onset epilepsy, comparing those with and without lesional epilepsy.

METHODS

In this observational study we used Truven Health MarketScan databases derived from commercial health insurance, Medicare and Medicaid claims covering at least 5 years, commencing in 2008. We identified incident epilepsy cases based on International Classification of Diseases, Ninth Revision, Clinical Modification codes indicating epilepsy or recurrent seizures, taking into account antiepileptic drug (AED) claims, consistent with International League Against Epilepsy Commission on Epidemiology recommendations. We identified patients with lesional epilepsy when associated diagnoses indicated central nervous system infection, neoplasm, traumatic brain injury, stroke, senile dementia and static encephalopathy. Lesional and nonlesional cohorts were matched 1:1 on baseline characteristics of age, sex and insurance type for group comparisons.

RESULTS

In unmatched cohorts lesional epilepsy patients (N = 15,302) were more commonly older (mean age 48.7 years) compared with nonlesional epilepsy patients (N = 15,970; mean age 18.5 years). Among lesional patients <20 years of age, the leading putative etiology was static encephalopathy, while among ages ≥20 years and older, the leading putative etiology was stroke or cerebrovascular disease. In matched cohorts (7063 patients each), those with lesional epilepsy were significantly less likely to be untreated at 1 year versus those with nonlesional epilepsy (37.2% vs 56.1%). In children and adults among matched cohorts, levetiracetam was the most common AED prescribed for initial AED therapy for the lesional (39.5%) and nonlesional (32.1%) groups. Lesional epilepsy patients on monotherapy were only slightly less likely than nonlesional epilepsy patients to be on the same AED 1 year after treatment initiation (55.6% vs 59.7%).

SIGNIFICANCE

Compared with patients with lesional epilepsy, a higher proportion of patients with nonlesional epilepsy remain untreated 1 year after diagnosis. There were differences in AED selection by epilepsy etiology; levetiracetam is the most commonly prescribed drug for both cohorts.

Independent role of neonatal seizures in subsequent neurological outcomes: a population-based study

AIM

This population-based study aimed to estimate the impact of neonatal seizures on subsequent neurological outcomes, regardless of underlying etiology.

METHOD

We performed a retrospective cohort study (1st January 2009-31st December 2014), using a USA nationwide claims database. Newborn infants enrolled in 2009 were followed for up to 6 years. Neonatal seizures were identified by combining the International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of 779.0 (convulsions in newborn), procedure codes of electroencephalogram and brain imaging, and antiepileptic drugs claims. Cox regression models were built to estimate the independent impact of neonatal seizures on developing epilepsy, intellectual disability, psychiatric/behavioral disorders, and headache.

RESULTS

Out of 490 071 newborn infants (251 850 males [51.4%], 238 221 females [48.6%]), 800 neonatal seizure cases were identified. After controlling for sex, birthweight, preterm birth status, and underlying etiology, neonates with seizures were more likely to have epilepsy (hazard ratio=32.7; 95% confidence interval [CI]=27.7-38.7; p<0.001), intellectual disability (hazard ratio=2.0; 95% CI=1.8-2.3; p<0.001), and headache (hazard ratio=1.6; 95% CI=1.1-2.2; p=0.013) than those without seizures.

INTERPRETATION

Observed covariates being equal, seizures in neonates appeared to play a significant role in developing epilepsy, intellectual disability, and headache. The findings showed a detrimental impact of the event in the very early life on neurological outcomes in later life.

WHAT THIS PAPER ADDS

Seizures had their own impact on the development of adverse neurological outcomes. The magnitude of impact was quite large in epilepsy.

Assessment and effect of a gap between new-onset epilepsy diagnosis and treatment in the US

Objective

To estimate the treatment gap between a new epilepsy diagnosis and antiepileptic drug (AED) initiation in the United States.

Methods

Retrospective claims-based cohort study using Truven Health MarketScan databases (commercial and supplemental Medicare, calendar years 2010–2015; Medicaid, 2010–2014) and a validation study using PharMetrics Plus Database linked to LRx claims database (2009–2014). Persons met epilepsy diagnostic criteria, had an index date (first epilepsy diagnosis) with a preceding 2-year baseline (1 year for persons aged 1 to <2 years; none for persons <1 year), and continuous medical and pharmacy enrollment without epilepsy/seizure diagnosis or AED prescription during baseline. Outcomes included percentage of untreated persons (no AED prescription) up to 3 years' follow-up and comparative outcomes (incidence rate ratio: untreated persons/treated persons), including medical events and health care resource utilization.

Results

In the primary study, 59,970 persons met selection (or inclusion) criteria; 36.7% of persons with newly diagnosed epilepsy remained untreated up to 3 years after diagnosis. In the validation study (N = 30,890), 31.8% of persons remained untreated up to 3 years after diagnosis. Lack of AED treatment was associated with an adjusted incidence rate ratio (95% confidence interval) of 1.2 (1.2–1.3) for medical events, 2.3 (2.2–2.3) for hospitalizations, and 2.8 (2.7–2.9) for emergency department visits.

Conclusions

One-third of newly diagnosed persons remain untreated up to 3 years after epilepsy diagnosis. The increased risk of medical events and health care utilization highlights the consequences of delayed treatment after epilepsy diagnosis, which might be preventable.

The primary prevention of epilepsy: A report of the Prevention Task Force of the International League Against Epilepsy

Among the causes of epilepsy are several that are currently preventable. In this review, we summarize the public health burden of epilepsy arising from such causes and suggest priorities for primary epilepsy prevention. We conducted a systematic review of published epidemiologic studies of epilepsy of 4 preventable etiologic categories-perinatal insults, traumatic brain injury (TBI), central nervous system (CNS) infection, and stroke. Applying consistent criteria, we assessed the quality of each study and extracted data on measures of risk from those with adequate quality ratings, summarizing findings across studies as medians and interquartile ranges. Among higher-quality population-based studies, the median prevalence of active epilepsy across all ages was 11.1 per 1000 population in lower- and middle-income countries (LMIC) and 7.0 per 1000 in high-income countries (HIC). Perinatal brain insults were the largest attributable fraction of preventable etiologies in children, with median estimated fractions of 17% in LMIC and 15% in HIC. Stroke was the most common preventable etiology among older adults with epilepsy, both in LMIC and in HIC, accounting for half or more of all new onset cases. TBI was the attributed cause in nearly 5% of epilepsy cases in HIC and LMIC. CNS infections were a more common attributed cause in LMIC, accounting for about 5% of all epilepsy cases. Among some rural LMIC communities, the median proportion of epilepsy cases attributable to endemic neurocysticercosis was 34%. A large proportion of the overall public health burden of epilepsy is attributable to preventable causes. The attributable fraction for perinatal causes, infections, TBI, and stroke in sum reaches nearly 25% in both LMIC and HIC. Public health interventions addressing maternal and child health care, immunizations, public sanitation, brain injury prevention, and stroke prevention have the potential to significantly reduce the burden of epilepsy.

National Association of Medical Examiners Position Paper: Recommendations for the Investigation and Certification of Deaths in People with Epilepsy

Sudden unexpected death of an individual with epilepsy (SUDEP) can pose a challenge to death investigators, as most deaths are unwitnessed and the individual is commonly found dead in bed. Anatomic findings (e.g., tongue/lip bite) are commonly absent and of varying specificity, limiting the evidence to implicate epilepsy as a cause of or contributor to death. Thus, it is likely that death certificates significantly underrepresent the true number of deaths in which epilepsy was a factor. To address this, members of the National Association of Medical Examiners, North American SUDEP Registry, Epilepsy Foundation SUDEP Institute, American Epilepsy Society, and the Centers for Disease Control and Prevention convened an expert panel to generate evidence-based recommendations for the practice of death investigation and autopsy, toxicological analysis, interpretation of autopsy and toxicology findings, and death certification to improve the precision of death certificate data available for public health surveillance of epilepsy-related deaths. The recommendations provided in this paper are intended to assist medical examiners, coroners, and death investigators when a sudden, unexpected death in a person with epilepsy is encountered.

Comorbidities and risk factors associated with newly diagnosed epilepsy in the U.S. pediatric population

Neurobehavioral comorbidities can be related to underlying etiology of epilepsy, epilepsy itself, and adverse effects of antiepileptic drugs. We examined the relationship between neurobehavioral comorbidities and putative risk factors for epilepsy in children with newly diagnosed epilepsy. We conducted a retrospective analysis of children aged ≤18years in 50 states and the District of Columbia, using the Truven Health MarketScan® commercial claims and encounters database from January 1, 2009 to December 31, 2013. The eligible study cohort was continuously enrolled throughout 2013 as well as enrolled for any days during a baseline period of at least the prior 2years. Newly diagnosed cases of epilepsy were defined by International Classification of Diseases, Ninth Revision, Clinical Modification-coded diagnoses of epilepsy or recurrent seizures and evidence of prescribed antiepileptic drugs during 2013, when neither seizure codes nor seizure medication claims were recorded during baseline periods. Twelve neurobehavioral comorbidities and eleven putative risk factors for epilepsy were measured. More than 6 million children were analyzed (male, 51%; mean age, 8.8years). A total of 7654 children were identified as having newly diagnosed epilepsy (125 per 100,000, 99% CI=122-129). Neurobehavioral comorbidities were more prevalent in children with epilepsy than children without epilepsy (60%, 99% CI=58.1-61.0 vs. 23%, CI=23.1-23.2). Children with epilepsy were far more likely to have multiple comorbidities (36%, 99% CI=34.3-37.1) than those without epilepsy (8%, 99% CI=7.45-7.51, P<0.001). Preexisting putative risk factors for epilepsy were detected in 28% (99% CI=26.9-29.6) of children with epilepsy. After controlling for demographics, neurobehavioral comorbidities, family history of epilepsy, and other risk factors than primary interest, neonatal seizures had the strongest independent association with the development of epilepsy (OR=29.8, 99% CI=23.7-37.3, P<0.001). Compared with children with risk factors but no epilepsy, those with both epilepsy and risk factors were more likely to have intellectual disabilities (OR=13.4, 99% CI=11.9-15.0, P<0.001). The epilepsy and intellectual disabilities could share the common pathophysiology in the neuronal network.

Premature mortality of epilepsy in low- and middle-income countries: A systematic review from the Mortality Task Force of the International League Against Epilepsy

To determine the magnitude of risk factors and causes of premature mortality associated with epilepsy in low- and middle-income countries (LMICs). We conducted a systematic search of the literature reporting mortality and epilepsy in the World Bank-defined LMICs. We assessed the quality of the studies based on representativeness; ascertainment of cases, diagnosis, and mortality; and extracted data on standardized mortality ratios (SMRs) and mortality rates in people with epilepsy. We examined risk factors and causes of death. The annual mortality rate was estimated at 19.8 (range 9.7-45.1) deaths per 1,000 people with epilepsy with a weighted median SMR of 2.6 (range 1.3-7.2) among higher-quality population-based studies. Clinical cohort studies yielded 7.1 (range 1.6-25.1) deaths per 1,000 people. The weighted median SMRs were 5.0 in male and 4.5 in female patients; relatively higher SMRs within studies were measured in children and adolescents, those with symptomatic epilepsies, and those reporting less adherence to treatment. The main causes of death in people with epilepsy living in LMICs include those directly attributable to epilepsy, which yield a mean proportional mortality ratio (PMR) of 27.3% (range 5-75.5%) derived from population-based studies. These direct causes comprise status epilepticus, with reported PMRs ranging from 5 to 56.6%, and sudden unexpected death in epilepsy (SUDEP), with reported PMRs ranging from 1 to 18.9%. Important causes of mortality indirectly related to epilepsy include drowning, head injury, and burns. Epilepsy in LMICs has a significantly greater premature mortality, as in high-income countries, but in LMICs the excess mortality is more likely to be associated with causes attributable to lack of access to medical facilities such as status epilepticus, and preventable causes such as drowning, head injuries, and burns. This excess premature mortality could be substantially reduced with education about the risk of death and improved access to treatments, including AEDs.

The burden of premature mortality of epilepsy in high-income countries: A systematic review from the Mortality Task Force of the International League Against Epilepsy

Since previous reviews of epidemiologic studies of premature mortality among people with epilepsy were completed several years ago, a large body of new evidence about this subject has been published. We aim to update prior reviews of mortality in epilepsy and to reevaluate and quantify the risks, potential risk factors, and causes of these deaths. We systematically searched the Medline and Embase databases to identify published reports describing mortality risks in cohorts and populations of people with epilepsy. We reviewed relevant reports and applied criteria to identify those studies likely to accurately quantify these risks in representative populations. From these we extracted and summarized the reported data. All population-based studies reported an increased risk of premature mortality among people with epilepsy compared to general populations. Standard mortality ratios are especially high among people with epilepsy aged <50 years, among those whose epilepsy is categorized as structural/metabolic, those whose seizures do not fully remit under treatment, and those with convulsive seizures. Among deaths directly attributable to epilepsy or seizures, important immediate causes include sudden unexpected death in epilepsy (SUDEP), status epilepticus, unintentional injuries, and suicide. Epilepsy-associated premature mortality imposes a significant public health burden, and many of the specific causes of death are potentially preventable. These require increased attention from healthcare providers, researchers, and public health professionals.

Epilepsy or seizure disorder? The effect of cultural and socioeconomic factors on self-reported prevalence

Self-reported epilepsy may be influenced by culture, knowledge, and beliefs. We screened 6420 residents of the District of Columbia (DC) for epilepsy to investigate whether socio-demographics were associated with whether they reported their diagnosis as epilepsy or as seizure disorder. Lifetime and active prevalence rates were 0.54% and 0.21%, respectively for 'epilepsy' and 1.30% and 0.70%, respectively for 'seizure disorder'. Seizure disorder was reported significantly more often than epilepsy among blacks, females, respondents≥50years, those with lower level education, respondents who lived alone and in low income neighborhoods, and those who resided in DC for at least five years. Clinicians should assure that patients and caregivers understand that epilepsy is synonymous with seizure disorder and other culturally appropriate terms, in order to optimize compliance with treatment, disease management instructions, and utilization of other resources targeted at persons with epilepsy. Furthermore, education and awareness campaigns aimed at improving access-to-care, reducing stigma, and increasing awareness of adverse events, such as SUDEP, should include a more diverse definition of epilepsy in their messages.

Estimating Epilepsy Incidence and Prevalence in the US Pediatric Population Using Nationwide Health Insurance Claims Data

This study aims to determine prevalence and incidence of epilepsy in the US pediatric population. We analyzed commercial claims and Medicaid insurance claims data between 2008 and 2012. Over 8 million continuously enrolled lives aged 0 to 19 years were included. Our definition of a prevalent case of epilepsy was based on International Classification of Diseases-coded diagnoses of epilepsy or seizures and evidence of prescribed antiepileptic drugs. Incident cases were identified in subjects continuously enrolled for ≥2 years of which the first 2 years had no indication of epilepsy or seizures. The overall prevalence estimate for 2012 was 6.8 per 1,000 children. The overall incidence estimate for 2012 was 104 per 100,000 pediatric population. This study provides estimates of the prevalence and incidence of epilepsy in the US pediatric population, using large claims datasets from multiple US population sectors. The findings appear reasonably representative of the US-insured pediatric population.

Health-care access among adults with epilepsy: The U.S. National Health Interview Survey, 2010 and 2013

INTRODUCTION

Community-based and other epidemiologic studies within the United States have identified substantial disparities in health care among adults with epilepsy. However, few data analyses addressing their health-care access are representative of the entire United States. This study aimed to examine national survey data about adults with epilepsy and to identify barriers to their health care.

MATERIALS AND METHODS

We analyzed data from U.S. adults in the 2010 and the 2013 National Health Interview Surveys, multistage probability samples with supplemental questions on epilepsy. We defined active epilepsy as a history of physician-diagnosed epilepsy either currently under treatment or accompanied by seizures during the preceding year. We employed SAS-callable SUDAAN software to obtain weighted estimates of population proportions and rate ratios (RRs) adjusted for sex, age, and race/ethnicity.

RESULTS

Compared to adults reporting no history of epilepsy, adults reporting active epilepsy were significantly more likely to be insured under Medicaid (RR=3.58) and less likely to have private health insurance (RR=0.58). Adults with active epilepsy were also less likely to be employed (RR=0.53) and much more likely to report being disabled (RR=6.14). They experience greater barriers to health-care access including an inability to afford medication (RR=2.40), mental health care (RR=3.23), eyeglasses (RR=2.36), or dental care (RR=1.98) and are more likely to report transportation as a barrier to health care (RR=5.28).

CONCLUSIONS

These reported substantial disparities in, and barriers to, access to health care for adults with active epilepsy are amenable to intervention.

The Epidemiology of Traumatic Brain Injury in Children and Youths: A Review of Research Since 1990

This report reviews recent research on the epidemiology of traumatic brain injuries among children and youth aged 0 to 20 years. Studies representing populations in North America, Europe, Australia, and New Zealand yield these median estimates of the annual incidence of childhood brain injuries: 691 per 100 000 population treated in emergency departments, 74 per 100 000 treated in hospital, and 9 per 100 000 resulting in death. Males have a higher risk of injury than females: 1.4 times higher among those aged less than 10 years and 2.2 times among those older than 10 years. The leading cause of injury among children aged less than 5 years is falls, whereas the leading cause of injury among youths aged 15 years and older is motor vehicle crashes. The prevalence of disability among all persons who have sustained traumatic brain injury in childhood is unknown, but among those who were hospitalized could approximate 20%.

Prevalence of pediatric epilepsy in low-income rural Midwestern counties

Epilepsy is one of the most common disabling neurological disorders, but significant gaps exist in our knowledge about childhood epilepsy in rural populations. The present study assessed the prevalence of pediatric epilepsy in nine low-income rural counties in the Midwestern United States overall and by gender, age, etiology, seizure type, and syndrome. Multiple sources of case identification were used, including medical records, schools, community agencies, and family interviews. The prevalence of active epilepsy was 5.0/1000. Prevalence was 5.1/1000 in males and 5.0/1000 in females. Differences by age group and gender were not statistically significant. Future research should focus on methods of increasing study participation in rural communities, particularly those in which research studies are rare.

Descriptive epidemiology of epilepsy in the U.S. population: A different approach

OBJECTIVE

Determine prevalence and incidence of epilepsy within two health insurance claims databases representing large sectors of the U.S.

METHODS

A retrospective observational analysis using Commercial Claims and Medicare (CC&M) Supplemental and Medicaid insurance claims data between January 1, 2007 and December 31, 2011. Over 20 million continuously enrolled lives of all ages were included. Our definition of a prevalent case of epilepsy was based on International Classification of Diseases, Ninth Revision, Clinical Modification-coded diagnoses of epilepsy or seizures and evidence of prescribed antiepileptic drugs. Incident cases were identified among prevalent cases continuously enrolled for ≥ 2 years before the year of incidence determination with no epilepsy, seizure diagnoses, or antiepileptic drug prescriptions recorded.

RESULTS

During 2010 and 2011, overall age-adjusted prevalence estimate, combining weighted estimates from all datasets, was 8.5 cases of epilepsy/1,000 population. With evaluation of CC&M and Medicaid data separately, age-adjusted prevalence estimates were 5.0 and 34.3/1,000 population, respectively, for the same period. The overall age-adjusted incidence estimate for 2011, combining weighted estimates from all datasets, was 79.1/100,000 population. Age-adjusted incidence estimates from CC&M and Medicaid data were 64.5 and 182.7/100,000 enrollees, respectively. Incidence data should be interpreted with caution due to possible misclassification of some prevalent cases.

SIGNIFICANCE

The large number of patients identified as having epilepsy is statistically robust and provides a credible estimate of the prevalence of epilepsy. Our study draws from multiple U.S. population sectors, making it reasonably representative of the U.S.-insured population.

Newer antiepileptic drug use and other factors decreasing hospital encounters

A retrospective analysis was conducted in one claims database and was confirmed in a second independent database (covering both commercial and government insurance plans between 11/2009 and 9/2011) for the understanding of factors influencing antiepileptic drug (AED) use and the role of AEDs and other health-care factors in hospital encounters. In both datasets, epilepsy cases were identified by AED use and epilepsy diagnosis coding. Variables analyzed for effect on hospitalization rates were as follows: (1) use of first-generation AEDs or second-generation AEDs, (2) treatment changes, and (3) factors that may affect AED choice. Lower rates of epilepsy-related hospital encounters (encounters with an epilepsy diagnosis code) were associated with use of second-generation AEDs, deliberate treatment changes, and treatment by a neurologist. Epilepsy-related hospital encounters were more frequent for patients not receiving an AED and for those with greater comorbidities. On average, patients taking ≥1 first-generation AED experienced epilepsy-related hospitalizations every 684days, while those taking ≥1second-generation AED were hospitalized every 1001days (relative risk reduction of 31%, p<0.01). Prescriptions for second-generation AEDs were more common among neurologists and among physicians near an epilepsy center. Use of second-generation AEDs, access to specialty care, and deliberate efforts to change medications following epilepsy-related hospital encounters improved outcomes of epilepsy treatment based on average time between epilepsy-related hospital encounters. These factors may be enhanced by public health policies, private insurance reimbursement policies, and education of patients and physicians.

Association of statin use with peripheral neuropathy in the U.S. population 40 years of age or older

BACKGROUND

Peripheral neuropathy is a serious complication of diabetes and several conditions that may lead to the loss of lower extremity function and even amputations. Since the introduction of statins, their use has increased markedly. Recent reports suggest a role for statins in the development of peripheral neuropathy. The aims of the present study were to assess the association between statin use and peripheral neuropathy, and to determine whether this association varied by diabetes status.

METHODS

Data from the lower extremity examination supplement of the 1999-2004 National Health and Nutrition Examination Survey were used.

RESULTS

The overall prevalence of statin use was 15% and the prevalence of peripheral neuropathy was 14.9%. The prevalence of peripheral neuropathy was significantly higher among those who used statins compared with those who did not (23.5% vs 13.5%, respectively; P < 0.01). Multivariate logistic regression revealed that statin use (adjusted odds ratio 1.3; 95% confidence interval 1.1-1.6; Wald P = 0.04) was significantly associated with peripheral neuropathy, controlling for diabetes status, age, gender, race, height, weight, blood lead levels, poverty, glycohemoglobin, use of vitamin B12 , alcohol abuse, hypertension, and non-high-density lipoprotein-cholesterol. Diabetes status, age, gender, height, weight, blood lead levels, poverty, and glycohemoglobin were also significantly associated with peripheral neuropathy. We found no effect modification between statin use and diabetes status, race, gender, age, vitamin B12 , blood lead levels, or alcohol abuse.

CONCLUSIONS

In the present cross-sectional study, we found a modest association between peripheral neuropathy and statin use. Prospective studies are required to determine the causal direction.

Summary of evidence-based guideline update: evaluation and management of concussion in sports: report of the Guideline Development Subcommittee of the American Academy of Neurology

OBJECTIVE

To update the 1997 American Academy of Neurology (AAN) practice parameter regarding sports concussion, focusing on 4 questions: 1) What factors increase/decrease concussion risk? 2) What diagnostic tools identify those with concussion and those at increased risk for severe/prolonged early impairments, neurologic catastrophe, or chronic neurobehavioral impairment? 3) What clinical factors identify those at increased risk for severe/prolonged early postconcussion impairments, neurologic catastrophe, recurrent concussions, or chronic neurobehavioral impairment? 4) What interventions enhance recovery, reduce recurrent concussion risk, or diminish long-term sequelae? The complete guideline on which this summary is based is available as an online data supplement to this article.

METHODS

We systematically reviewed the literature from 1955 to June 2012 for pertinent evidence. We assessed evidence for quality and synthesized into conclusions using a modified Grading of Recommendations Assessment, Development and Evaluation process. We used a modified Delphi process to develop recommendations.

RESULTS

Specific risk factors can increase or decrease concussion risk. Diagnostic tools to help identify individuals with concussion include graded symptom checklists, the Standardized Assessment of Concussion, neuropsychological assessments, and the Balance Error Scoring System. Ongoing clinical symptoms, concussion history, and younger age identify those at risk for postconcussion impairments. Risk factors for recurrent concussion include history of multiple concussions, particularly within 10 days after initial concussion. Risk factors for chronic neurobehavioral impairment include concussion exposure and APOE ε4 genotype. Data are insufficient to show that any intervention enhances recovery or diminishes long-term sequelae postconcussion. Practice recommendations are presented for preparticipation counseling, management of suspected concussion, and management of diagnosed concussion.

Racial and socioeconomic disparities in epilepsy in the District of Columbia

We investigated social and demographic factors as they relate to prevalence and incidence of epilepsy in Washington, DC, a culturally diverse area. Probability-based sampling was used to select 20,000 households to complete a mailed epilepsy screening survey on all household members. Screened individuals with a history of epilepsy were sent a detailed case survey about seizures and treatment. Prevalence and incidence of epilepsy were estimated using weighted data. Lifetime prevalence was 1.53% overall; 0.77% in Whites, 2.13% in Blacks, and 3.4% in those with less than a high school diploma. Prevalence of active epilepsy was 0.79% and followed similar subgroup comparisons as lifetime prevalence. Age-adjusted lifetime and active epilepsy from multivariate analyses demonstrated significantly higher rates for Blacks compared to Whites and for those not completing high school compared to those that attended graduate school. The incidence of epilepsy was 71 per 100,000 persons. Adults with active epilepsy were significantly less likely to live alone than those without epilepsy. Residents of DC for <4 years had the lowest prevalence and incidence of all subgroups indicating a possible healthy mover effect. This is the first study to provide estimates and profiles of the epilepsy population in DC which can help better target resources to improve the health and outcomes of people with epilepsy and their families.

Standards for epidemiologic studies and surveillance of epilepsy

Worldwide, about 65 million people are estimated to have epilepsy. Epidemiologic studies are necessary to define the full public health burden of epilepsy; to set public health and health care priorities; to provide information needed for prevention, early detection, and treatment; to identify education and service needs; and to promote effective health care and support programs for people with epilepsy. However, different definitions and epidemiologic methods complicate the tasks of these studies and their interpretations and comparisons. The purpose of this document is to promote consistency in definitions and methods in an effort to enhance future population-based epidemiologic studies, facilitate comparison between populations, and encourage the collection of data useful for the promotion of public health. We discuss: (1) conceptual and operational definitions of epilepsy, (2) data resources and recommended data elements, and (3) methods and analyses appropriate for epidemiologic studies or the surveillance of epilepsy. Variations in these are considered, taking into account differing resource availability and needs among countries and differing purposes among studies.

Effect of exercise on cognitive performance in community-dwelling older adults: review of intervention trials and recommendations for public health practice and research

There is evidence from observational studies that increasing physical activity may reduce the risk of cognitive decline in older adults. Exercise intervention trials have found conflicting results. A systematic review of physical activity and exercise intervention trials on cognition in older adults was conducted. Six scientific databases and reference lists of previous reviews were searched. Thirty studies were eligible for inclusion. Articles were grouped into intervention-outcome pairings. Interventions were grouped as cardiorespiratory, strength, and multicomponent exercises. Cognitive outcomes were general cognition, executive function, memory, reaction time, attention, cognitive processing, visuospatial, and language. An eight-member multidisciplinary panel rated the quality and effectiveness of each pairing. Although there were some positive studies, the panel did not find sufficient evidence that physical activity or exercise improved cognition in older adults. Future research should report exercise adherence, use longer study durations, and determine the clinical relevance of measures used.

Adverse antiepileptic drug effects in new-onset seizures: a case-control study

OBJECTIVE

Adverse effects (AEs) are a major concern when starting antiepileptic drug (AED) treatment. This study quantified the extent to which AE reporting in people with new-onset seizures started on AEDs is attributable to the medication per se, and investigated variables contributing to AE reporting.

METHODS

We pooled data from 2 large prospective studies, the Multicenter Study of Early Epilepsy and Single Seizures and the Northern Manhattan Study of incident unprovoked seizures, and compared adverse event profile (AEP) total and factor scores between adult cases prescribed AEDs for new-onset seizures and untreated controls, adjusting for several demographic and clinical variables. Differences in AEP scores were also tested across different AED monotherapies and controls, and between cases and controls grouped by number of seizures.

RESULTS

A total of 212 cases and 206 controls were identified. Most cases (94.2%) were taking low AED doses. AEP scores did not differ significantly between the 2 groups. Depression, female gender, symptomatic etiology, younger seizure onset age, ≥2 seizures, and history of febrile seizures were associated with higher AEP scores. There were no significant differences in AEP scores across different monotherapies and controls. AEP scores increased in both cases and controls with increasing number of seizures, the increment being more pronounced in cases.

CONCLUSIONS

When AED treatment is started at low doses following new-onset seizures, AE reporting does not differ from untreated individuals. Targeting specific factors affecting AE reporting could lead to improved tolerability of epilepsy treatment.

Unmet health care needs among CSHCN with neurologic conditions

OBJECTIVE

Children with neurologic conditions require a variety of services. With this study we examined health care needs and unmet needs among children with neurologic conditions.

METHODS

Cross-sectional data reported by parents of 3- to 17-year-olds in the 2005-2006 National Survey of Children With Special Health Care Needs were analyzed. Demographic characteristics, health care needs, and unmet needs of children with special health care needs (CSHCN) and neurologic conditions were descriptively compared with an independent referent group of children without special health care needs; statistical contrasts were performed as a function of the type (conditions included in the Diagnostic and Statistical Manual of Mental Disorders [DSM] or not) and number of reported neurologic conditions.

RESULTS

Compared with the parents of children without special health care needs, parents of CSHCN with neurologic conditions were more likely to report unmet health care needs for their child. After adjustment for demographic factors and severity of functional limitation, CSHCN with at least 2 conditions had more visits to a health care provider, needed more services, and reported more unmet needs than CSHCN with a single DSM condition. The magnitude of need among CSHCN was greatest among those with at least 1 of each type of neurologic condition.

CONCLUSIONS

Unmet health care needs exist among CSHCN with neurologic conditions and are particularly pronounced among children with a combination of both DSM and non-DSM disorders. The health care needs among CSHCN with multiple neurologic conditions may be better served by targeted efforts to improve care coordination.

A population-based study of risk of epilepsy after hospitalization for traumatic brain injury

PURPOSE

This study was undertaken to determine the risk of developing posttraumatic epilepsy (PTE) within 3 years after discharge among a population-based sample of older adolescents and adults hospitalized with traumatic brain injury (TBI) in South Carolina. It also identifies characteristics related to development of PTE within this population.

METHODS

A stratified random sample of persons aged 15 and older with TBI was selected from the South Carolina nonfederal hospital discharge dataset for four consecutive years. Medical records of recruits were reviewed, and they participated in up to three yearly follow-up telephone interviews.

RESULTS

The cumulative incidence of PTE in the first 3 years after discharge, after adjusting for loss to follow-up, was 4.4 per 100 persons over 3 years for hospitalized mild TBI, 7.6 for moderate, and 13.6 for severe. Those with severe TBI, posttraumatic seizures prior to discharge, and a history of depression were most at risk for PTE. This higher risk group also included persons with three or more chronic medical conditions at discharge.

DISCUSSION

These results raise the possibility that although some of the characteristics related to development of PTE are nonmodifiable, other factors, such as depression, might be altered with intervention. Further research into factors associated with developing PTE could lead to risk-reducing treatments.

Disparities in epilepsy: report of a systematic review by the North American Commission of the International League Against Epilepsy

PURPOSE

We undertook a systematic review of the evidence on disparities in epilepsy with a focus on North American data (Canada, United States, and the English-speaking Caribbean).

METHODS

We identified and evaluated: access to and outcomes following medical and surgical treatment, disability, incidence and prevalence, and knowledge and attitudes. An exhaustive search (1965-2007) was done, including: (1) disparities by socioeconomic status (SES), race/ethnicity, age, or education of subgroups of the epilepsy population; or (2) disparities between people with epilepsy (PWE) and healthy people or with other chronic illnesses.

RESULTS

From 1,455 citations, 278 eligible abstracts were identified and 44 articles were reviewed. Comparative research data were scarce in all areas. PWE have been shown to have lower education and employment status; among PWE, differences in access to surgery have been shown by racial/ethnic groups. Aboriginals, women, and children have been shown to differ in use of health resources. Poor compliance has been shown to be associated with lower SES, insufficient insurance, poor relationship with treating clinicians, and not having regular responsibilities.

DISCUSSION

Comprehensive, comparative research on all aspects of disparities in epilepsy is needed to understand the causes of disparities and the development of any policies aimed at addressing health disparities and minimizing their impact.

Antiepileptic drug use in women of childbearing age

Research on antiepileptic drug (AED) teratogenesis has demonstrated an increased risk for valproate. The impact of these findings on current AED prescribing patterns for women of childbearing age with epilepsy is uncertain. The Neurodevelopmental Effects of Antiepileptic Drugs (NEAD) Study is an ongoing prospective multicenter observational investigation that enrolled pregnant women with epilepsy on the most common AED monotherapies from October 1999 to February 2004 (carbamazepine, lamotrigine, valproate, and phenytoin). A 2007 survey of AED use in women of childbearing age at eight NEAD centers found a total of 932 women of childbearing age with epilepsy (6% taking no AED, 53% monotherapy, 41% polytherapy). The most common monotherapies were lamotrigine or levetiracetam. Since 2004, prescriptions of carbamazepine, phenytoin, and valproate have decreased, whereas those for levetiracetam have increased. Except for the top two AED monotherapies, there were marked differences in other monotherapies and in polytherapies between U.S. and UK centers. Future investigations are needed to examine reasons for drug choice.

Epilepsy surveillance among adults--19 States, Behavioral Risk Factor Surveillance System, 2005

PROBLEM/CONDITION

Epilepsy is a brain disorder characterized by brief, recurrent disturbances in the normal electrical functions of the brain that result in seizures. Few population-based studies of epilepsy have been published for the United States, and the prevalence is expected to increase with the aging of the population. This is the first multistate study examining the prevalence of self-reported epilepsy and active epilepsy and includes an examination of socioedemographic and behavioral characteristics and of health-related quality of life among adults with epilepsy.

REPORTING PERIOD COVERED

Data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS) are presented for 19 states.

DESCRIPTION OF SYSTEM

BRFSS is an ongoing, state-based, random-digit--dialed telephone survey of the noninstitutionalized U.S. population aged >/=18 years. BRFSS collects information on health risk behaviors and preventive health services related to leading causes of death and morbidity. In 2005, 19 states included questions on epilepsy or seizure disorder.

RESULTS/INTERPRETATION

During 2005, 1.65% of noninstitutionalized adults from 19 states reported that they had ever been told by a doctor that they had epilepsy or seizure disorder (i.e., a history of epilepsy); 0.84% reported having active epilepsy (i.e., a history of epilepsy and currently taking medication or reporting one or more seizures during the past 3 months), and 0.75% were classified as having inactive epilepsy (i.e., a history of epilepsy or seizure disorder but currently not taking medicine to control epilepsy and no seizures in the 3 months preceding the survey). No substantial differences among states in the prevalence of lifetime epilepsy, active epilepsy, or inactive epilepsy were detected. Prevalence estimates for active and inactive epilepsy revealed no significant differences by sex or race/ethnicity. Adults with a history of epilepsy and with active epilepsy were more likely to report fair or poor health, be unemployed or unable to work, live in households with the lowest annual incomes, and have a history of co-occurring disorders (e.g., stroke or arthritis). Adults with a history of epilepsy and with active epilepsy also reported significantly worse health-related quality of life. Adults with a history of epilepsy were more likely to be obese, physically inactive, and current smokers. Among adults with active epilepsy with recent seizures, 16.1% reported not currently taking their epilepsy medication, and 65.1% reported having had more than one seizure in the past month. Among adults with a history of epilepsy, 23.7% reported cost as a barrier to seeking care from a doctor within the past year. A total of 34.9% of adults with active epilepsy with seizures reported not having seen a neurologist or an epilepsy specialist (i.e., a neurologist who specializes in treating epilepsy) in the previous year.

PUBLIC HEALTH ACTION

Additional descriptive and analytic studies of epilepsy occurrence in diverse U.S. communities and populations are needed to better characterize epilepsy incidence rates, risk factors and etiologies, and types and severity, as well as epilepsy-associated conditions and disabilities. Community-based strategies that link health- care providers with social services such as public transportation, mental health services, and employment services might improve quality of life in persons with epilepsy. Implementing educational programs developed by CDC and the Epilepsy Foundation for schools, emergency responders, employers, providers, and the general public can increase awareness about epilepsy and reduce stigma associated with this disorder.

Prevalence of Active Epilepsy and Health-Related Quality of Life among Adults with Self-Reported Epilepsy in California: California Health Interview Survey, 2003

PURPOSE

To examine the prevalence of self-reported epilepsy and active epilepsy, associated burden of impaired health-related quality of life, risk factors, and access to care in adults with self-reported epilepsy, and those classified as having active epilepsy with and without recent seizures.

METHODS

We analyzed data from adults aged >or=18 years (n = 41,494) who participated in the 2003 California Health Interview Survey (CHIS).

RESULTS

In California, 1.2% of adults reported ever being told they had epilepsy or seizure disorder, and 0.7% were classified as having active epilepsy. About three-fourths of adults with active epilepsy with recent seizures reported fair or poor health status. Adults with active epilepsy with recent seizures reported almost two weeks of poor physical or mental health and activity limitation days compared with two to 4 days per month in those without epilepsy. Among adults with active epilepsy and recent seizures, about one-quarter reported not taking any medicine to control their seizure disorder or epilepsy. About one-third reported physical disability/unable to work compared to a small proportion of the general population. The majority of adults with active epilepsy reported having a regular source of medical care.

CONCLUSION

Our findings highlight the burden of epilepsy among adults in California. CHIS serves as a model demonstrating the value of including questions about epilepsy on public health surveillance systems to ascertain the burden of the disorder and to guide intervention research and public policy to improve HRQOL in people with epilepsy.

How common are the "common" neurologic disorders?

OBJECTIVE

To estimate the current incidence and prevalence in the United States of 12 neurologic disorders.

METHODS

We summarize the strongest evidence available, using data from the United States or from other developed countries when US data were insufficient.

RESULTS

For some disorders, prevalence is a better descriptor of impact; for others, incidence is preferable. Per 1,000 children, estimated prevalence was 5.8 for autism spectrum disorder and 2.4 for cerebral palsy; for Tourette syndrome, the data were insufficient. In the general population, per 1,000, the 1-year prevalence for migraine was 121, 7.1 for epilepsy, and 0.9 for multiple sclerosis. Among the elderly, the prevalence of Alzheimer disease was 67 and that of Parkinson disease was 9.5. For diseases best described by annual incidence per 100,000, the rate for stroke was 183, 101 for major traumatic brain injury, 4.5 for spinal cord injury, and 1.6 for ALS.

CONCLUSIONS

Using the best available data, our survey of a limited number of disorders shows that the burden of neurologic illness affects many millions of people in the United States.

Prevalence of Self-Reported Epilepsy or Seizure Disorder and Its Associations with Self-Reported Depression and Anxiety: Results from the 2004 Healthstyles Survey

PURPOSE

To examine the prevalence of self-reported epilepsy or seizure disorder and its association with self-reported recent depression and anxiety in a large sample of the U.S. adult population.

METHODS

We analyzed data from adults aged 18 years or older (n = 4,345) who participated in the 2004 HealthStyles Survey, a large mail panel survey designed to be representative of the U.S. population.

RESULTS

Among U.S. adults aged 18 years or older, we estimated that 2.9% have been told by a doctor that they had epilepsy or seizure disorder, and an estimated 1.6% and 0.9% had active and inactive epilepsy, respectively. After controlling for demographic characteristics, we estimated that adults with self-reported epilepsy were twice as likely to self-report depression or anxiety in the previous year as were adults without epilepsy, and adults with active epilepsy were 3 times as likely to self-report depression and twice as likely to have anxiety in the previous year as were adults without epilepsy.

CONCLUSIONS

Our findings highlight the burden of self-reported depression and anxiety among adults with self-reported epilepsy or seizure disorder, and suggest that healthcare providers should attempt to determine whether adult patients with epilepsy have any psychiatric comorbidity potentially to improve health outcomes. Questions about epilepsy and related factors should be routinely included on population-based surveys so that we can better understand the epilepsy distribution in the U.S. population and identify the unmet health and psychosocial needs of people with epilepsy.

Psychological distress, comorbidities, and health behaviors among U.S. adults with seizures: results from the 2002 National Health Interview Survey

PURPOSE

To examine the association of seizures with health-related quality of life (HRQOL), physical and psychiatric comorbidities, and health behaviors.

METHODS

We analyzed data obtained from adults aged 18 years or older (n = 30,445) who participated in the 2002 National Health Interview Survey, an ongoing, computer-assisted personal interview of the noninstitutionalized U.S. population.

RESULTS

An estimated 1.4% of adults 18 years or older reported being told by a health care professional that they had seizures. Persons with seizures were significantly more likely than those without seizures to report lower levels of education, higher levels of unemployment, pain, hypersomnia and insomnia, and psychological distress (e.g., feelings of sadness, nervousness, hopelessness, and worthlessness). In addition, they were significantly more likely to report insufficient leisure-time physical activity as well as physical comorbidities such as cancer, arthritis, heart disease, stroke, asthma, severe headaches, lower back pain, and neck pain.

CONCLUSIONS

Our findings suggest that it is advisable for health care professionals to assess psychiatric and physical comorbidities among patients with a history of seizures potentially to improve patient health outcomes. Furthermore, public health surveillance systems should include questions on seizures, epilepsy, and mental health to better examine associations among these disorders and to better identify populations meriting further assessment and intervention.

Psychological distress, comorbidities, and health behaviors among U.S. adults with seizures: results from the 2002 National Health Interview Survey

PURPOSE

To examine the association of seizures with health-related quality of life (HRQOL), physical and psychiatric comorbidities, and health behaviors.

METHODS

We analyzed data obtained from adults aged 18 years or older (n = 30,445) who participated in the 2002 National Health Interview Survey, an ongoing, computer-assisted personal interview of the noninstitutionalized U.S. population.

RESULTS

An estimated 1.4% of adults 18 years or older reported being told by a health care professional that they had seizures. Persons with seizures were significantly more likely than those without seizures to report lower levels of education, higher levels of unemployment, pain, hypersomnia and insomnia, and psychological distress (e.g., feelings of sadness, nervousness, hopelessness, and worthlessness). In addition, they were significantly more likely to report insufficient leisure-time physical activity as well as physical comorbidities such as cancer, arthritis, heart disease, stroke, asthma, severe headaches, lower back pain, and neck pain.

CONCLUSIONS

Our findings suggest that it is advisable for health care professionals to assess psychiatric and physical comorbidities among patients with a history of seizures potentially to improve patient health outcomes. Furthermore, public health surveillance systems should include questions on seizures, epilepsy, and mental health to better examine associations among these disorders and to better identify populations meriting further assessment and intervention.

Estimating Prevalence, Incidence, and Disease-related Mortality for Patients with Epilepsy in Managed Care Organizations

PURPOSE

The purpose of the present study was to apply computer algorithms to an administrative data set to identify the prevalence of epilepsy, incidence of epilepsy, and epilepsy-related mortality of patients in a managed care organization (MCO).

METHODS

The study population consisted of members enrolled in Lovelace Health Plan, a component of Lovelace Health Systems, a statewide MCO headquartered in Albuquerque, New Mexico. Patient records were obtained from July 1996 to June 2001. Four logistic regression models with high sensitivity and specificity were applied to 1-, 3-, and 5-year time frames in which members were continuously enrolled in the MCO. Incidence was defined for patients who did not have an epilepsy-associated code in the 18 months before the first diagnosis entry. Mortality estimates in the population also were assessed by using a matched control group and linkage to a statewide death registry.

RESULTS

The data yielded estimated prevalence rates of 7-10 per 1,000, depending on age, sex, ethnicity, and time interval. Annualized incidence was 47 per 100,000 for members continuously enrolled for 3 years and 71 per 100,000 for members continuously enrolled for 5 years. Crude mortality rates were 2-2.5 times higher for epilepsy patients identified with the algorithms than for the matched controls. Conditional logistic regression indicated that the odds of death for epilepsy patients as compared with controls ranged from 1.24 to 2.06.

CONCLUSIONS

Accurate estimation of prevalence, incidence, and mortality rates for epilepsy is an essential component of disease management in MCOs. The algorithms in this project can be used to monitor trends in prevalence, incidence, and mortality to inform decisions critical to improving the health care needs and quality of life for patients with epilepsy.

Developing a Computer Algorithm to Identify Epilepsy Cases in Managed Care Organizations

The goal of this study was to develop an algorithm for detecting epilepsy cases in managed care organizations (MCOs). A data set of potential epilepsy cases was constructed from an MCO's administrative data system for all health plan members continuously enrolled in the MCO for at least 1 year within the study period of July 1, 1996 through June 30, 1998. Epilepsy status was determined using medical record review for a sample of 617 cases. The best algorithm for detecting epilepsy cases was developed by examining combinations of diagnosis, diagnostic procedures, and medication use. The best algorithm derived in the exploratory phase was then applied to a new set of data from the same MCO covering the period of July 1, 1998 through June 30, 2000. A stratified sample based on ethnicity and age was drawn from the preliminary algorithm-identified epilepsy cases and non-cases. Medical record review was completed for 644 cases to determine the accuracy of the algorithm. Data from both phases were combined to permit refinement of logistic regression models and to provide more stable estimates of the parameters. The best model used diagnoses and antiepileptic drugs as predictors and had a positive predictive value of 84% (sensitivity 82%, specificity 94%). The best model correctly classified 90% of the cases. A stable algorithm that can be used to identify epilepsy patients within MCOs was developed. Implications for use of the algorithm in other health care settings are discussed.

Developing a measure to assess attitudes toward epilepsy in the US population

The aim of this study was to develop an instrument to measure the US public's attitudes toward people with epilepsy and to assess the initial reliability and validity of the instrument. A 46-item attitudinal instrument was developed and tested using a proportional, stratified, national, random-digit dial household telephone survey of adults aged > or = 18 (n=758). Exploratory factor analyses revealed four underlying constructs that accounted for 34.4% of the variance in the factor analysis: negative stereotypes (alpha=0.73); risk and safety concerns (alpha=0.85); work and role expectations (alpha=0.76); and personal fear and social avoidance (alpha=0.79). Knowledge was also assessed; participants with less knowledge about epilepsy had more negative attitudes. The results of these analyses provided evidence for reliability and construct validity of the instrument. Additional tests of the reliability, validity, and factor structure of the scales are necessary to refine the instrument.

Prevalence of epilepsy and health status of adults with epilepsy in Georgia and Tennessee: Behavioral Risk Factor Surveillance System, 2002

Behavioral risk factors associated with comorbidity in people with epilepsy are largely unknown. We studied a population-based sample of 8057 adults through the 2002 Behavioral Risk Factor Surveillance System, in Georgia and Tennessee, ascertaining a lifetime epilepsy prevalence of 2.1% in this population. This structured interview revealed that those with epilepsy had significantly worse self-reported fair or poor health status (39% vs 17% in adults without epilepsy), significantly greater cigarette smoking (38.8% vs 24.9% in other adults), and high rates of obesity (34.1% vs 23.7% in adults without epilepsy). Large percentages of adults with epilepsy reported currently symptomatic asthma and recent joint pain. Adults with epilepsy had lower educational attainment and lower household incomes, but a higher rate of medical insurance coverage, than did other adults. This type of population-based survey can serve to identify health disparities, behavioral risk factors for other chronic diseases, and unmet health care needs in individuals with epilepsy, and to track changes in these measures over time.

Estimating Nonfatal Traumatic Brain Injury Hospitalizations Using an Urban/Rural Index

OBJECTIVE

To develop state-level estimates of the annual number of nonfatal cases of traumatic brain injury (TBI) resulting in hospitalization.

METHODS

The estimation process incorporates annual nonfatal TBI hospitalization case counts from 15 states funded by the Centers for Disease Control and Prevention to conduct TBI surveillance; annual fatal TBI case counts based on National Center for Health Statistics data for all 50 states; and an index reflecting the urban/rural character of each state. These data are used to develop a negative binomial regression model that yields estimates of the annual number of nonfatal TBI hospitalization cases for each state not funded to conduct TBI surveillance.

RESULTS

Sensitivity analysis suggests that on average the estimates fall within +/- 15% of the case counts that would be obtained directly from surveillance.

CONCLUSION

In combination, the TBI case count data and the urban/rural index support effective modeling and estimation of annual nonfatal TBI hospitalization case counts at the state level.

Traumatic brain injury-related hospital discharges. Results from a 14-state surveillance system, 1997

PROBLEM/CONDITION

Previous studies indicate that each year in the United States, approximately 1.5 million Americans sustain a traumatic brain injury (TBI). Of those injured, approximately one quarter million are hospitalized. Approximately one third of adults hospitalized with TBI still need help with daily activities 1 year after their discharge.

REPORTING PERIOD

This report summarizes surveillance data for TBI in the United States for January-December 1997.

DESCRIPTION OF THE SYSTEM

Data are from 14 states that participated in an ongoing CDC-funded TBI surveillance system. State health departments used CDC guidelines to identify TBI cases from hospital discharge data or from other statewide injury data systems. Supplementary information was abstracted from medical records.

RESULTS

The overall age-adjusted TBI-related live hospital discharge rate was 69.7/100,000 population. Rates were highest for American Indians and Alaska Natives (75.3/100,000) and Blacks (74.4/100,000). The age-adjusted rate for males was approximately twice as high as for females (91.9 versus 47.7/100,000 respectively). For both sexes, the rates were highest among those aged 15-19 years and >/= 65 years. Motor-vehicle crashes, falls, and assaults were the leading causes of injury for TBI-related discharges (27.9, 22.5, and 7.3/100,000 respectively). TBI-related discharge rates for falls were highest among those aged >/= 65 years (82.3/100,000). Black males and American Indian/Alaska Native males had the highest rates of TBI attributable to assault (31.3 and 29.5 per 100,000, respectively), approximately 4 times the rate for white males. An estimated 46% of injured motor-vehicle occupants, 53% of motorcyclists, and 41% of pedal cyclists reportedly were not using personal protective equipment (PPE) (e.g., seat belts or helmets) at the time of their TBI. With regard to outcome assessed before discharge from the hospital, approximately 17% of persons hospitalized with TBI had moderate to severe disability.

INTERPRETATION

Data in this report, the most extensive to date from a multistate population-based TBI surveillance system, indicate the importance of TBI as a public health problem. Population-based information regarding TBI hospitalizations can be useful in assessing the effect of prevention efforts and planning for the service needs of persons with TBI.

Surveillance for traumatic brain injury deaths--United States, 1989-1998

PROBLEM/CONDITION

Data indicate that approximately 50,000 U.S. residents die as a result of traumatic brain injury (TBI) annually. Survivors of TBI are often left with neuropsychologic impairments that result in disabilities affecting work or social activity. During 1979-1992, TBI-related death rates declined 22%, from 24.6 to 19.3 deaths/100,000 population. This report describes the epidemiology and trends in TBI-related mortality during 1989-1998.

REPORTING PERIOD

January 1, 1989-December 31, 1998.

DESCRIPTION OF SYSTEMS

The National Center for Health Statistics (NCHS) Multiple Cause of Death public use data were analyzed for this study.

RESULTS

During 1989-1998, an annual average of 53,288 deaths (range: 51,848-54,501) among U.S. residents were associated with TBI. TBI-related death rates declined 11.4%, from 21.9 to 19.4/100,000 population. The major causes of TBI-related deaths were firearm-related (40%), motor-vehicle-related (34%), and fall-related (10%). The leading causes of TBI-related deaths differed among age groups. Among youths aged 0-19 years, motor-vehicle-related TBIs were the leading cause; among persons aged 20-74 years, firearm-related TBIs were the leading cause; and among persons aged > or = 75 years, fall-related TBIs were the leading cause. Comparing rates in 1989 with rates in 1998, motor-vehicle-related causes declined by 22%; the majority of this decline occurred during the first 5 years of the period. During 1989-1998, firearm-related TBI-related deaths declined by 14%; approximately all of this decline occurred during the last 5 years of the period. In contrast, fall-related TBI-related death rates increased by 25% during the period.

CONCLUSION

This analysis of mortality data identifies recent trends in TBI-related deaths occurring during 1989-1998. Fall-related TBI death rates have increased throughout the period. Firearm-related TBI death rates, which were increasing in the early 1990s, declined. Motor-vehicle-related TBI death rates, which were decreasing until the mid-1990s, have since demonstrated only a limited change.

PUBLIC HEALTH ACTION

More current population-based epidemiologic studies of TBI are needed to assess recent trends of etiologic factors, provide additional guidance for public policy, and evaluate prevention strategies. Despite the decline in fatal TBI incidence, TBI morbidity and mortality remains a public health challenge. Public health, law enforcement, and transportation safety professionals can address these challenges by implementing effective interventions based on a thorough assessment of the factors that influence health-related behaviors.