High-Value Epilepsy Care in the United States: Predictors of Increased Costs and Complications from the National Inpatient Sample Database 2016-2019

BACKGROUND

For patients with medically refractory epilepsy, newer minimally invasive techniques such as laser interstitial thermal therapy (LITT) have been developed in recent years. This study aims to characterize trends in the utilization of surgical resection versus LITT to treat medically refractory epilepsy, characterize complications, and understand the cost of this innovative technique to the public.

METHODS

The National Inpatient Sample database was queried from 2016 to 2019 for all patients admitted with a diagnosis of medically refractory epilepsy. Patient demographics, hospital length of stay, complications, and costs were tabulated for all patients who underwent LITT or surgical resection within these cohorts.

RESULTS

A total of 6019 patients were included, 223 underwent LITT procedures, while 5796 underwent resection. Significant predictors of increased patient charges for both cohorts included diabetes (odds ratio: 1.7, confidence interval [CI]: 1.44-2.19), infection (odds ratio: 5.12, CI 2.73-9.58), and hemorrhage (odds ratio: 2.95, CI 2.04-4.12). Procedures performed at nonteaching hospitals had 1.54 greater odds (CI 1.02-2.33) of resulting in a complication compared to teaching hospitals. Insurance status did significantly differ (P = 0.001) between those receiving LITT (23.3% Medicare; 25.6% Medicaid; 44.4% private insurance; 6.7 Other) and those undergoing resection (35.3% Medicare; 22.5% Medicaid; 34.7% private Insurance; 7.5% other). When adjusting for patient demographics, LITT patients had shorter length of stay (2.3 vs. 8.9 days, P < 0.001), lower complication rate (1.9% vs. 3.1%, P = 0.385), and lower mean hospital ($139,412.79 vs. $233,120.99, P < 0.001) and patient ($55,394.34 vs. $37,756.66, P < 0.001) costs.

CONCLUSIONS

The present study highlights LITT's advantages through its association with lower costs and shorter length of stay. The present study also highlights the associated predictors of LITT versus resection, such as that most LITT cases happen at academic centers for patients with private insurance. As the adoption of LITT continues, more data will become available to further understand these issues.

Community health workers to improve adherence to anti-seizure medication in rural South Africa: Is it cost-effective?

OBJECTIVE

Epilepsy is a common, chronic neurological disorder that disproportionately affects individuals living in low- and middle-income countries (LMICs), where the treatment gap remains high and adherence to medication remains low. Community health workers (CHWs) have been shown to be effective at improving adherence to chronic medications, yet no study assessing the costs of CHWs in epilepsy management has been reported.

METHODS

Using a Markov model with age- and sex-varying transition probabilities, we determined whether deploying CHWs to improve epilepsy treatment adherence in rural South Africa would be cost-effective. Data were derived using published studies from rural South Africa. Official statistics and international disability weights provided cost and health state values, respectively, and health gains were measured using quality adjusted life years (QALYs).

RESULTS

The intervention was estimated at International Dollars ($) 123 250 per annum per sub-district community and cost $1494 and $1857 per QALY gained for males and females, respectively. Assuming a costlier intervention and lower effectiveness, cost per QALY was still less than South Africa's Gross Domestic Product per capita of $13 215, the cost-effectiveness threshold applied.

SIGNIFICANCE

CHWs would be cost-effective and the intervention dominated even when costs and effects of the intervention were unfavorably varied. Health system re-engineering currently underway in South Africa identifies CHWs as vital links in primary health care, thereby ensuring sustainability of the intervention. Further research on understanding local health state utility values and cost-effectiveness thresholds could further inform the current model, and undertaking the proposed intervention would provide better estimates of its efficacy on reducing the epilepsy treatment gap in rural South Africa.

Cost of epilepsy-related health care encounters in the United States

BACKGROUND: The cost of epilepsy is usually reported as total expenditure over a certain period. However, with the increased availability of acute treatments for use in the community setting, intermittent, single-seizure treatment is now possible in addition to the chronic epilepsy drug treatment paradigm. Data on the cost of discrete health care encounters are needed to substantiate the cost-benefit of these new treatments. OBJECTIVE: To estimate the health plan-paid costs of discrete epilepsy-related health care encounters in patients with epilepsy. METHODS: This retrospective cohort study utilized IBM MarketScan Commercial Claims, Medicare Supplemental and Coordination of Benefits (Medicare patients with supplemental insurance), and Multi-State Medicaid research databases. The primary analysis determined health plan-paid cost (adjudicated claims) of discrete epilepsy-related health care encounters, defined as having a primary diagnosis code of epilepsy or convulsion, from 2013 to 2018, in patients with epilepsy aged ≥ 12 years. Costs were adjusted to 2018 prices. Epilepsy cases were defined using ICD-CM codes. We excluded patients on capitated insurance plans as their cost per health care encounter is unknown. RESULTS: In total, 353,530 commercially insured, 378,051 Medicaid, and 69,176 Medicare plus supplemental insurance patients with epilepsy were included. More than 160,000 epilepsy-related emergency transportations, 225,000 emergency department (ED) visits, 49,000 hospitalizations, 700 urgent care visits, and ~2.5 million office visits were analyzed. 37.4% of epilepsy-related hospitalizations included care in the intensive care unit (ICU). In commercially insured patients, epilepsy-related health care encounters had median health plan-paid costs of $22,305 (Q1-Q3 = $14,336-$36,096, hospitalization); $3,375 ($565-$9,095, ICU visit); $1,913 ($417-$4,163, ED visit); $687 ($415-$1,083, emergency transportation); $95 ($23-$232, office visit); and $57 ($0-$171, urgent care visit). The median length of stay for epilepsy-related hospitalizations in working age, commercially insured patients was 4 (Q1-Q3 = 2-5) days. CONCLUSIONS: This is the first study to report health plan-paid cost per epilepsy-related health care encounter. These data can serve as a basis for more granular cost-benefit analyses of not only chronic but also acute treatments of epilepsy. DISCLOSURES: This analysis was funded by UCB Pharma. The sponsor had a role in the identification, design, conduct, and reporting of the analysis. Borghs, Beaty, Boudiaf, and Loewendorf are employees of UCB Pharma. Kalilani and Parekh were employees of UCB Pharma at the time of the analysis. Borghs, Beaty, and Loewendorf have received UCB Pharma stock from their employment. Kalilani and Parekh had received UCB Pharma stock at the time of employment, but no longer hold any. This work was presented in part as a poster at the 73rd Annual Meeting of the American Epilepsy Society; December 7, 2019; Baltimore, MD.

Economic burden of the persistent morbidity of nodding syndrome on caregivers in affected households in Northern Uganda

BACKGROUND

Nodding syndrome (NS), is an unexplained form of epilepsy which leads to stunted growth, cognitive decline, and a characteristic nodding of the head. Current data about its impact on households in Uganda is scarce. Therefore, this study aims to assess the economic burden of the persistent morbidity of NS on caregivers in affected households in Northern Uganda.

METHODS

A cross-sectional cost-of-care study was conducted from January 2019 to February 2019 in Lakwela village-Northern Uganda in 14 households, who are members of a community-based organization (CBO) established in the village with the support of a Japanese research team, (Uganda-Japan Nodding Syndrome Network). Data was collected through questionnaires. Both direct (medical and non-medical) and indirect (informal care) costs of caregiving were assessed. Indirect costs were valued using the human-capital method as loss of production.

RESULTS

Direct costs constituted a higher proportion of costs for NS households, accounting for on average 7.7% of household expenditure. The annual weighted mean cost per NS patient was estimated at 27.6 USD (26.4 USD direct costs, 96.2% and 1.2 USD indirect cost, 3.8%). Average time spent on informal caregiving was 4.4 ±1.7 (standard deviation) hours/week with an estimated annual informal caregiving cost of 24.85 USD and gross domestic product (GDP) loss of 412.40 USD.

CONCLUSION

Direct costs due to NS are still high among households in this study. More studies are needed to investigate measures that could help bring down these costs and equally reduce the day-to-day disruption of caregiver's activities; consequently, improving the lives of these affected households and communities.

Cost-benefit analysis, cost-effectiveness analysis, and impact of antiepileptic drugs on the risk of fracture in patients with epilepsy: A nationwide cohort study

PURPOSE

Although nonenzyme-inducing antiepileptic drugs (nEIAEDs) are accepted for the treatment of epilepsy, few studies have examined the costs, benefits, and cost-effectiveness of nEIAEDs in relation to the incidence of fracture among patients with epilepsy. In the present study, we performed cost-benefit and cost-effectiveness analyses comparing the influence of enzyme-inducing AEDs (EIAEDs) and nEIAEDs on the risk of fracture in this population.

METHODS

A total of 4864 patients with epilepsy were classified into EIAED and nEIAED groups. Propensity score matching was applied to reduce the influence of selection bias. Clinical outcomes were measured in relation to AED fee, medical expenses associated with epilepsy and fracture, and the total number of fractures. Cost-benefit and cost-effectiveness analyses were performed for all patients.

RESULTS

Patients in the unmatched EIAED cohort (n = 3686) were older and had more comorbidities. After matching, the cohorts exhibited similar features (n = 2432 each). Fracture risk was lower in the nEIAED group than in the EIAED group (HR = 0.70). The additional medical expense of nEIAEDs in fractures and epilepsy for 2 years per person was 107,731 New Taiwan dollars (NT$). The additional cost for nEIAEDs to reduce one event of fracture was $14,789,421 NT$.

CONCLUSIONS

Patients with epilepsy using nEIAEDs had a lower risk of fracture than those using EIAEDs. However, the cost-benefit ratio and cost-effectiveness of such treatment were lower in the nEIAED group than in the EIAED group.

The economic burden of caregiving in epilepsy: An estimate based on a survey of US caregivers

OBJECTIVE

The burden of caregiving for persons with epilepsy (PWEs) has not been examined previously in the United States. We assessed the clinical impact and direct and indirect economic costs for caregivers of PWEs.

METHODS

An internet survey of 500 caregivers of PWEs was conducted from May to July 2015 using a combination of validated instruments and questions designed specifically for this survey. Caregivers were stratified by PWE age (adult/child) and disease severity (low: 0 vs high: 1 + seizures in the prior month). Annual self-reported direct and indirect costs were reported per caregiver and extrapolated to all US caregivers. The economic burden of caregiving for PWEs was defined as the difference between costs for caregivers and the general population.

RESULTS

Caregivers reported that PWEs averaged 11.4 seizures in the prior month. Eighty percent of respondents were female and the average age was 44.3. Since becoming a caregiver, many reported anxiety (52.8%), depression (41.0%), and insomnia (30.8%). Annual mean direct medical costs for caregivers of children with low vs high seizure frequency were $4344 and $10 162, respectively. Costs for caregivers of adult PWEs were $4936 and $8518. Mean indirect costs associated with caregiving for a child with low vs high seizure frequency were $20 529 and $40 137; those for caregivers of an adult were $13 981 and $28 410. The cost estimates are higher vs the general US population; annual per-person healthcare utilization costs were $2740 and productivity loss costs were $5015. When extrapolating to the US population of PWE caregivers, annual costs exceeded $62 billion vs $14 billion for the general population, resulting in a caregiver burden of nearly $48 billion.

SIGNIFICANCE

The clinical and economic burden of caregivers for PWE were substantial, and greatest for those caring for children with frequent seizures. The impact on caregivers should be considered when estimating the value of interventions that control epilepsy.

Trajectories of poverty and economic hardship among American families supporting a child with a neurodisability

BACKGROUND

Caring for a child with a neurodisability (ND) impacts the financial decisions, relationships and well-being of family members, but evidence on the economic trajectories of families throughout the life course is missing.

METHODS

Using data from the Panel Study of Income Dynamics, we tracked the families of 3317 children starting 5 years before childbirth until the child reached 20 years of age. We used regression and latent growth curve modelling to estimate trajectories of poverty and economic hardship over time.

RESULTS

Families with a child with an ND had higher rates of poverty and economic hardship prior to childbirth and persistently over time. Analysis uncovered five latent trajectories for each indicator. After controlling for family and caregiver characteristics that preceded the birth of the child, raising a child with an ND was not associated with a unique trajectory of poverty. Families raising a child with an ND were however more likely to experience persistent economic hardship.

CONCLUSIONS

The study establishes descriptive evidence for how having a child with an ND relates to changes in family economic conditions. The social and economic conditions that precede the child's birth seem to be driving the economic inequalities observed later throughout the life course.

School status and its associations among children with epilepsy in the Republic of Guinea

BACKGROUND

In low-income countries (LICs), there are multiple barriers for children with epilepsy (CWE) to attend school. We examined potentially modifiable associations with poor school performance in CWE in the West African Republic of Guinea.

METHODS

Children with epilepsy of school age were recruited using public announcements and a clinical register of people with epilepsy at the Ignace Deen Hospital in Conakry in 2018. A team of Guinean and U.S. neurologists and neurologists-in-training interviewed each CWE and parent for his/her epilepsy history, household finances, educational attainment level, and perceived stigma using the Stigma Scale of Epilepsy (SSE). Each child was also tested using the Wechsler Nonverbal Scale of Ability (WNV). Low school performance was defined as either not attending school or being held back a grade level at least once. Potential predictors of low school performance were analyzed.

FINDINGS

Of 128 CWE (mean age: 11.6 years, 48.4% female), 11.7% (n = 15) never attended school, 23.3% (n = 30) dropped out, and 64.8% (n = 83) were currently enrolled. Of CWE attending school, 46.9% (n = 39) were held back a grade level. Overall, 54 children were defined as low performers (LPs) (42%). ;Greater than 100 lifetime seizures (odds ratio (OR) = 8.81; 95% confidence interval (CI) = 2.51, 37.4; p = 0.001) and lower total WNV score (OR = 0.954; 95% CI = 0.926, 0.977; p < 0.001) were significantly associated with poor school performance in separate models, when controlling for potential confounders. Given the strong relationship between seizure freedom and school performance, we estimated that 38 additional CWE (33.6%) could become high performers (HPs) if all CWE were adequately treated to achieve the lifetime seizure category of <10 seizures and could be cognitively intact again. Models examining SSE and household wealth quintile were not significantly associated with school performance.

CONCLUSIONS

Higher lifetime seizures and lower WNV score were significantly associated with low school performance in CWE in Guinea. In spite of our conservative definition of high school performance (attending without failing) and risk of referral bias at an academic center where patients were allowed to self-refer, we demonstrate that seizure control in this setting could increase the number of CWE who could attend and stay in school.

National declines in the percentages of uninsured among adults aged 18-64 years with active epilepsy, 2010 and 2013 to 2015 and 2017-U.S. National Health Interview Survey

Epilepsy is more common among children and adults living in households at lowest incomes. Like those living with any complex chronic condition, people with epilepsy need quality healthcare to improve their health and social outcomes. The purpose of this study was to use the latest national data to provide updated estimates of the percentages of adults aged 18-64 years with active epilepsy who were uninsured in 2010, 2013, 2015, and 2017 and to examine changes in health insurance coverage during these years. We analyzed nationally representative samples of adults (aged 18-64 years) from the 2010, 2013, 2015, and 2017 National Health Interview Survey (NHIS). We used a validated epilepsy surveillance case definition to classify adults as having active epilepsy during 2010 and 2013 (n = 507) and during 2015 and 2017 (n = 582). We used the NHIS recode variables available in each year that account for a series of questions posed to respondents to confirm coverage and that ultimately classify respondents with different healthcare coverage types. Overall, the percentage of uninsured adults among respondents aged 18-64 years with active epilepsy decreased by more than half (59%), from 17.7% (95% confidence interval [CI] = 13.6%-22.7%) in 2010 and 2013 to 7.3% (95% CI = 4.8%-10.7%) in 2015 and 2017. The decrease in the percentage of uninsured adults with active epilepsy after 2010 and 2013 was balanced by a similar increase in public insurance coverage and private insurance coverage in 2015 and 2017. Epilepsy stakeholders can ensure that all uninsured adults with epilepsy obtain access to health insurance coverage. National Health Interview Survey data on epilepsy, when available, can be used to monitor trends in insurance status in the new decade.

The monetary burden of cysticercosis in Mexico

Background

Taenia solium cysticercosis is a public health and agricultural problem in many low and middle-income countries where health education, sanitation, pig management practices and meat inspection infrastructure are insufficient. Cysticercosis affects both human and animal health and has important economic consequences. Very few studies have been conducted to evaluate the monetary burden of cysticercosis. This study aimed at estimating the 2015 costs associated with cysticercosis in humans and pigs in Mexico.

Methods

The monetary burden of human cysticercosis was estimated based on costs incurred by living with and treating epilepsy and severe chronic headaches associated with neurocysticercosis (NCC). The estimated cost of porcine cysticercosis took into consideration losses due to the reduction in the price of cysticercosis-infected animals. Epidemiologic and economic data were obtained from the published literature, government reports, and setting-specific questionnaires. Latin hypercube sampling methods were employed to sample the distributions of uncertain parameters and to estimate 95% credible regions (95% CRs). All results are reported in 2015 U.S.$.

Findings

The overall monetary burden associated with NCC morbidity was estimated at U.S.$215,775,056 (95% CR U.S.$109,309,560 –U.S.$361,924,224), with U.S.$436 (95% CR: U.S.$296 –U.S.$604) lost per patient. If loss of future years of income and productivity due to NCC-associated deaths was included, this value increased by U.S.$54.26 million, assuming that these individuals earned Mexico’s median wage salary. An additional U.S.$19,507,171 (95% CR U.S.$5,734,782 –U.S.$35,913,487) was estimated to be lost due to porcine cysticercosis.

Conclusions

This study suggests that T. solium cysticercosis results in considerable monetary losses to Mexico.

Taenia solium cysticercosis is a parasitic disease, which can be transmitted between humans and pigs in areas of the world where pigs are raised in a traditional manner and latrines are not always used by the local population. Because cysticercosis affects humans and pigs, it is important to assess how much this infection costs both the public health and agricultural sectors in endemic countries such as Mexico. Costs associated with infection of both humans and pigs, in Mexico, were estimated using the literature, questionnaires, and publicly available data. Study findings suggest that T. solium cysticercosis results in considerable monetary losses to Mexico. The methodology developed here can be applied to estimate the monetary burden of cysticercosis in other regions in order to better prioritize disease control initiatives.

Experiences and needs of parents of young children with active epilepsy: A population-based study

The aim of the study was to gain a comprehensive understanding of the experiences and needs of parents of young children with epilepsy from a total population sample. The parents (mothers (n = 38), fathers (n = 9)) of 40/53 (75% of total population) young children (1-7 years; 23 males, 17 females) with 'active' epilepsy (had a seizure in the last year or taking Anti-epileptic drugs (AEDs)) were interviewed either in person or over the telephone using a semistructured interview schedule. The families were resident in the south of the UK. The interviews were audio-recorded, transcribed, and coded using thematic analysis. Thematic analysis revealed six main themes: diagnostic journey, parental perception of epilepsy management, awareness and impact of associated neurobehavioral difficulties, inconsistent availability of therapeutic and educational supports, impact on family functioning, and need for parental support. Parents reported often having difficulty accessing a professional knowledgeable about epilepsy. While parents were generally satisfied with the initial information they received about seizures and their management, they reported that the association between epilepsy and neurobehavioral issues was often not broached. These developmental/behavioral difficulties often had a bigger impact on child wellbeing and family functioning, but provision of therapeutic and educational supports for the difficulties was often very patchy. Parents noted that early onset epilepsy and associated neurobehavioral difficulties often have a very significant impact on family functioning including increased restrictions on family activities and increased financial burden. Parents would like informational and emotional support to extend beyond the time of epilepsy diagnosis. There is a clear need for comprehensive childhood epilepsy services to include provision for identification and management of child neurobehavioral needs and a focus on family-centered care.

Overall and cause-specific premature mortality in epilepsy: A systematic review

BACKGROUND

We conducted a systematic review to ascertain the overall mortality and causes of premature mortality in epilepsy.

METHODOLOGY

We searched PubMed and Embase to identify relevant articles reporting mortality in epilepsy. An assessment of the methodological quality and overall quality of evidence of the identified studies was done using appropriate checklists. We extracted data from these studies reporting measures of overall and cause-specific mortality in epilepsy.

RESULTS

Sixty-three articles from fifty-six cohorts met the eligibility criteria, thirty-three population- or community-based and twenty-three hospital- or institutional-based studies. The majority of studies are from high-income countries (HIC). These studies reported overall excess mortality for people with epilepsy, with wide variability reported for population- or community-based studies and from low- and middle-income countries (LMIC). Twenty-seven articles from twenty-three cohorts reported measures of mortality for cause-specific mortality in epilepsy. People with epilepsy from HIC and LMIC have a higher risk of dying from various causes compared with the general population. Those in LMIC, however, have a particularly high chance of dying from external causes such as drowning and suicide. We observed a decrement over time in measures of overall and cause-specific mortality in cohorts.

CONCLUSIONS

Despite the heterogeneity in reports, our findings support the suggestions that people with epilepsy have an increased risk of premature mortality from various causes. Further work is needed to elucidate the mechanisms, to determine biomarkers for predicting those at risk, and to understand the implications of counseling and preventive strategies.

Assessment of components included in published societal perspective or QALY outcome economic analyses for antiepileptic drug treatment in chronic epilepsy

INTRODUCTION

Antiepileptic drug (AED) treatments seek to control seizures with minimal or no adverse effects, effects which can substantially impact costs and outcomes for patients, caregivers, and third party payers. The First and Second Panel on Cost-Effectiveness in Health and Medicine recommend inclusion of a societal reference case, even in studies conducted from a healthcare sector perspective, for comparability of findings across studies. Cost and outcome evaluation components include direct medical, non-direct medical-related (e.g. patient-time and transportation costs for treatment) and non-healthcare sectors (e.g. lost productivity).

AREAS COVERED

Guided by Second Panel recommendations, this review developed an overall impact inventory and detailed adverse effect impact inventory to assess the scope and methods in published economic evaluations of AED treatments for adults with chronic epilepsy. Societal perspective evaluations or evaluations that utilized quality-adjusted life-years (QALYs) as an outcome were reviewed. The majority of reviewed articles were healthcare sector perspective studies, methods for estimating QALYs varied widely, and a minority considered specific AED treatment adverse effects.

EXPERT COMMENTARY

Only considering a healthcare sector perspective fails to provide full information for patients on AED treatments. Using an impact inventory to guide study scope and design will facilitate full reporting of costs and benefits.

A comparison of the responsiveness of EQ-5D-5L and the QOLIE-31P and mapping of QOLIE-31P to EQ-5D-5L in epilepsy

OBJECTIVE

To investigate the responsiveness of and correlation between the EQ-5D-5L and the QOLIE-31P in patients with epilepsy, and develop a mapping function to predict EQ-5D-5L values based on the QOLIE-31P for use in economic evaluations.

METHODS

The dataset was derived from two clinical trials, the ZMILE study in the Netherlands and the SMILE study in the UK. In both studies, patients' quality of life using the EQ-5D-5L and QOLIE-31P was measured at baseline and 12 months follow-up. Spearman's correlations, effect sizes (EF) and standardized response means (SRM) were calculated for both the EQ-5D-5L and QOLIE-31P domains and sub scores. Mapping functions were derived using ordinary least square (OLS) and censored least absolute deviations models.

RESULTS

A total of 509 patients were included in this study. Low to moderately strong significant correlations were found between both instruments. The EQ-5D-5L showed high ceiling effects and small EFs and SRMs, whereas the QOLIE-31P did not show ceiling effects and also showed small to moderate EFs and SRMs. Results of the different mapping functions indicate that the highest adjusted R ² we were able to regress was 0.265 using an OLS model with squared terms, leading to a mean absolute error of 0.103.

CONCLUSIONS

Results presented in this study emphasize the shortcomings of the EQ-5D-5L in epilepsy and the importance of the development of condition-specific preference-based instruments which can be used within the QALY framework. In addition, the usefulness of the constructed mapping function in economic evaluations is questionable.

Beliefs of a traditional rural Indian family towards naturalistic and faith healing for treating epilepsy: a case study

In this case study, we describe our experiences with a rural poor family from north India that initially contacted faith healers for treatment of their child who was having symptoms suggestive of epilepsy, but the seizures continued even after this. The family migrated to a city, where they started allopathic treatment, but eventually they had to discontinue it as there was no apparent relief. Again, they went back to their native village and restarted the treatment from the faith healer.This case study highlights the fact that in spite of the significant development of medical science, many questions pertaining to epilepsy treatment are still unanswered. Such dissatisfaction with the allopathic treatment of epilepsy is very common. Complexity of the disease and high cost of modern medication, side effects of drugs, efficient but heavy treatment protocols and unpredictable outcome are responsible for continued practice of people consulting faith healers for treatment of epilepsy. However, these remain unnoticed and undocumented.

Factors associated with ambulatory care sensitive emergency department visits for South Carolina Medicaid members with intellectual disability

INTRODUCTION

Ambulatory care sensitive conditions (ACSCs) can be seen as failure of access or management in primary care settings. Identifying factors associated with ACSCs for individuals with an Intellectual Disability (ID) provide insight into potential interventions.

METHOD

To assess the association between emergency department (ED) ACSC visits and a number of demographic and health characteristics of South Carolina Medicaid members with ID. A retrospective cohort of adults with ID was followed from 2001 to 2011. Using ICD-9-CM codes, four ID subgroups, totalling 14 650 members, were studied.

RESULTS

There were 106 919 ED visits, with 21 214 visits (19.8%) classified as ACSC. Of those, 82.9% were treated and released from EDs with costs averaging $578 per visit. People with mild and unspecified ID averaged greater than one ED visit per member year. Those with Down syndrome and other genetic cause ID had the lowest rates of ED visits but the highest percentage of ACSC ED visits that resulted in inpatient hospitalisation (26.6% vs. an average of 16.8% for other subgroups). When compared with other residential types, those residing at home with no health support services had the highest ED visit rate and were most likely to be discharged back to the community following an ED visit (85.2%). Adults residing in a nursing home had lower rates of ED visits but were most likely to be admitted to the hospital (38.9%) following an ED visit. Epilepsy and convulsions were the leading cause (29.6%) of ACSC ED visits across all subgroups and residential settings.

CONCLUSION

Prevention of ACSC ED visits may be possible by targeting adults with ID who live at home without health support services.

Understanding the health economic burden of patients with tuberous sclerosis complex (TSC) with epilepsy: a retrospective cohort study in the UK Clinical Practice Research Datalink (CPRD)

INTRODUCTION

Epilepsy is highly prevalent in tuberous sclerosis complex (TSC), a multi-system genetic disorder. The clinical and economic burden of this condition is expected to be substantial due to treatment challenges, debilitating co-morbidities and the relationship between TSC-related manifestations. This study estimated healthcare resource utilisation (HCRU) and costs for patients with TSC with epilepsy (TSC+E) in the UK.

METHODS

Patients with TSC+E in the Clinical Practice Research Datalink (CPRD) linked to Hospital Episodes Statistics were identified from April 1997 to March 2012. Clinical data were extracted over the entire history, and costs were reported over the most recent 3-year period. HCRU was compared with a matched Comparator cohort, and the key cost drivers were identified by regression modelling.

RESULTS

In total, 209 patients with TSC+E were identified, of which 40% recorded ≥2 other primary organ system manifestations and 42% had learning disability. Treatment with ≥2 concomitant antiepileptic drugs (AEDs) was prevalent (60%), potentially suggesting refractory epilepsy. Notwithstanding, many patients with TSC+E (12%) had no record of AED use in their entire history, which may indicate undertreatment for these patients.Brain surgery was recorded in 12% of patients. Routine electroencephalography and MRI were infrequently performed (30% of patients), yet general practitioner visits, hospitalisations and outpatient visits were more frequent in patients with TSC+E than the Comparator. This translated to threefold higher clinical costs (£14 335 vs £4448), which significantly increased with each additional primary manifestation (p<0.0001).

CONCLUSIONS

Patients with TSC+E have increased HCRU compared with the general CPRD population, likely related to manifestations in several organ systems, substantial cognitive impairment and severe epilepsy, which is challenging to treat and may be intractable. Disease surveillance and testing appears to be inadequate with few treatments trialled.Multidisciplinary care in TSC clinics with specialist neurologist input may alleviate some of the morbidity of patients, but more innovative treatment and management options should be sought.

Using routinely recorded data in the UK to assess outcomes in a randomised controlled trial: The Trials of Access

BACKGROUND

In the UK, routinely recorded data may benefit prospective studies including randomised controlled trials (RCTs). In an on-going study, we aim to assess the feasibility of access and agreement of routinely recorded clinical and non-clinical data compared to data collected during a RCT using standard prospective methods. This paper will summarise available UK routinely recorded data sources and discuss our experience with the feasibility of accessing routinely recorded data for participants of a RCT before finally proposing recommendations for improving the access and implementation of routinely recorded data in RCTs.

METHODS

Setting: the case study RCT is the Standard and New Antiepileptic Drugs II (SANAD II) trial, a pragmatic, UK, multicentre, phase IV RCT assessing the clinical and cost-effectiveness of antiepileptic drug treatments for newly diagnosed epilepsy.

PARTICIPANTS

98 participants have provided written consent to permit the request of routinely recorded data. Study procedures: routinely recorded clinical and non-clinical data were identified and data requested through formal applications from available data holders for the duration that participants have been recruited into SANAD II. The feasibility of accessing routinely recorded data during a RCT is assessed and recommendations for improving access proposed.

RESULTS

Secondary-care clinical and socioeconomic data is recorded on a national basis and can be accessed, although there are limitations in the application process. Primary-care data are recorded by a number of organisations on a de-identified basis but access for specific individuals has not been feasible. Access to data recorded by non-clinical sources, including The Department for Work and Pensions and The Driving and Vehicle Licensing Agency, was not successful.

CONCLUSIONS

Recommendations discussed include further research to assess the attributes of routinely recorded data, an assessment of public perceptions and the development of strategies to collaboratively improve access to routinely recorded data for research.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials, ISRCTN30294119 . Registered on 3 July 2012. EudraCT No: 2012-001884-64. Registered on 9 May 2012.

Economic analysis of an epilepsy outreach model of care in a university hospital setting

The prevalence of epilepsy in people with intellectual disability is higher than in the general population and prevalence rates increase with increasing levels of disability. Prevalence rates of epilepsy are highest among those living in residential care. The healthcare needs of people with intellectual disability and epilepsy are complex and deserve special consideration in terms of healthcare provision and access to specialist epilepsy clinics, which are usually held in acute hospital campuses. This patient population is at risk of suboptimal care because of significant difficulties accessing specialist epilepsy care which is typically delivered in the environs of acute hospitals. In 2014, the epilepsy service at Cork University Hospital established an Epilepsy Outreach Service providing regular, ambulatory outpatient follow up at residential care facilities in Cork city and county in an effort to improve access to care, reduce the burden and expense of patient and carer travel to hospital outpatient appointments, and to provide a dedicated specialist phone service for epilepsy related queries in order to reduce emergency room visits when possible. We present the findings of an economic analysis of the outreach service model of care compared to the traditional hospital outpatient service and demonstrate significant cost savings and improved access to care with this model. Ideally these cost savings should be used to develop novel ways to enhance epilepsy care for persons with disability. We propose that this model of care can be more suitable for persons with disability living in residential care who are at risk of losing access to specialist epilepsy care.

Reprint of "Neurocysticercosis-related mortality in Brazil, 2000-2011: Epidemiology of a neglected neurologic cause of death"

Neurocysticercosis (NCC) is an important cause of severe neurological disease mainly in low- and middle-income countries, but data on NCC mortality from endemic areas are scarce. Here we analysed the epidemiological patterns of NCC-related mortality in Brazil. We included all deaths recorded in Brazil between 2000 and 2011, in which NCC was mentioned on death certificates, either as underlying or as associated cause of death. NCC was identified in 1829/12,491,280 deaths (0.015%), 1130 (61.8%) as underlying cause, and 699 (38.2%) as associated cause. Overall age-adjusted mortality rate for the period was 0.97 deaths/1,000,000 inhabitants (95% confidence interval [CI]: 0.83-1.12). The highest NCC-related mortality rates were found in males, elderly, white race/colour and residents in endemic states/regions. Age-adjusted mortality rates at national level decreased significantly over time (annual percent change [APC]: -4.7; 95% CI: -6.0 to -3.3), with a decrease in the Southeast, South and Central-West regions, and a non-significant increasing trend in the North and Northeast regions. We identified spatial and spatiotemporal high-risk mortality clusters located mainly in NCC-endemic areas. Conditions related to the nervous system were the most commonly associated causes of death when NCC was mentioned as an underlying cause, and HIV/AIDS was the main underlying cause when NCC was an associated cause. NCC is a neglected and preventable cause of severe neurologic disease and death with high public health impact in Brazil. There is a clear need to strengthen nationwide epidemiological surveillance and control for the taeniasis/cysticercosis complex.

The direct costs of epilepsy in Russia. A prospective cost-of-illness study from a single center in Moscow

OBJECTIVE

The objective of this study was to investigate prospectively the direct costs of epilepsy in Russia, taking a patient perspective and a bottom-up approach.

METHODS

The study was conducted in adolescents and adults with epilepsy seen in the ambulatory services of a city hospital in Moscow. Patients were assigned to different prognostic categories: newly diagnosed epilepsy; epilepsy in remission for 2+years; epilepsy in remission for <2years or with occasional seizures; active, nondrug-resistant epilepsy; drug-resistant epilepsy; and drug-resistant epilepsy in surgical candidates. Patients were followed prospectively for 12months. Demographic and clinical features at admission were collected and correlated with costs. Cost estimates were based on the Russian National Health Service perspective and its implementation in Moscow. Cost items included drugs and laboratory/instrumental tests. The costs per patient were calculated for the entire sample and for each prognostic category separately. Univariate and multivariate analyses were performed.

RESULTS

Included were 738 patients (393 men, 345 women aged 14-85years). The median annual cost/patient was €955 (IQR 521-2134; range 51-10,904). The median cost of drugs was €643 (IQR 288-1866; range 0-9960), and the median cost of laboratory/instrumental testing was €202 (IQR 160-270; range 20-1217). Mean costs varied across prognostic categories ranging from €782 in newly diagnosed patients to €3777 in patients with drug-resistant epilepsy. Mean (SD) hospital costs ranged from €646.7 (109.0) in patients with occasional seizures to €950.0 (28.3) in surgical candidates. Independent predictors of total costs were younger age at diagnosis, disability status, generalized seizures, multiple seizure types, seizure severity, and etiology.

SIGNIFICANCE

The cost of epilepsy in Moscow varies significantly depending on disease characteristics and response to drug treatment.

Scaling-up essential neuropsychiatric services in Ethiopia: a cost-effectiveness analysis

INTRODUCTION

There is an immense need for scaling-up neuropsychiatric care in low-income countries. Contextualized cost-effectiveness analyses (CEAs) provide relevant information for local policies. The aim of this study is to perform a contextualized CEA of neuropsychiatric interventions in Ethiopia and to illustrate expected population health and budget impacts across neuropsychiatric disorders.

METHODS

A mathematical population model (PopMod) was used to estimate intervention costs and effectiveness. Existing variables from a previous WHO-CHOICE regional CEA model were substantially revised. Treatments for depression, schizophrenia, bipolar disorder and epilepsy were analysed. The best available local data on epidemiology, intervention efficacy, current and target coverage, resource prices and salaries were used. Data were obtained from expert opinion, local hospital information systems, the Ministry of Health and literature reviews.

RESULTS

Treatment of epilepsy with a first generation antiepileptic drug is the most cost-effective treatment (US$ 321 per DALY adverted). Treatments for depression have mid-range values compared with other interventions (US$ 457-1026 per DALY adverted). Treatments for schizophrenia and bipolar disorders are least cost-effective (US$ 1168-3739 per DALY adverted).

CONCLUSION

This analysis gives the Ethiopian government a comprehensive overview of the expected costs, effectiveness and cost-effectiveness of introducing basic neuropsychiatric interventions.

Can the Direct Medical Cost of Chronic Disease Be Transferred across Different Countries? Using Cost-of-Illness Studies on Type 2 Diabetes, Epilepsy and Schizophrenia as Examples

Objectives

To systematically review cost of illness studies for schizophrenia (SC), epilepsy (EP) and type 2 diabetes mellitus (T₂DM) and explore the transferability of direct medical cost across countries.

Methods

A comprehensive literature search was performed to yield studies that estimated direct medical costs. A generalized linear model (GLM) with gamma distribution and log link was utilized to explore the variation in costs that accounted by the included factors. Both parametric (Random-effects model) and non-parametric (Boot-strapping) meta-analyses were performed to pool the converted raw cost data (expressed as percentage of GDP/capita of the country where the study was conducted).

Results

In total, 93 articles were included (40 studies were for T₂DM, 34 studies for EP and 19 studies for SC). Significant variances were detected inter- and intra-disease classes for the direct medical costs. Multivariate analysis identified that GDP/capita (p<0.05) was a significant factor contributing to the large variance in the cost results. Bootstrapping meta-analysis generated more conservative estimations with slightly wider 95% confidence intervals (CI) than the parametric meta-analysis, yielding a mean (95%CI) of 16.43% (11.32, 21.54) for T₂DM, 36.17% (22.34, 50.00) for SC and 10.49% (7.86, 13.41) for EP.

Conclusions

Converting the raw cost data into percentage of GDP/capita of individual country was demonstrated to be a feasible approach to transfer the direct medical cost across countries. The approach from our study to obtain an estimated direct cost value along with the size of specific disease population from each jurisdiction could be used for a quick check on the economic burden of particular disease for countries without such data.

Clinical and economic burden of breakthrough seizures

PURPOSE

The purpose of this study was to measure health-care resource utilization and costs in treatment-adherent, previously seizure-free patients with epilepsy who were treated in the inpatient/emergency room (ER) setting for new-onset seizures, compared with matched controls.

METHODS

The study used a retrospective case/control study design using administrative claims from the IMS PharMetrics™ database. We identified adult patients with epilepsy with 1+ ER visit/hospitalization with primary diagnosis of epilepsy between 1/1/2006 and 3/31/2011, preceded by 6months of seizure-free activity and antiepileptic drug (AED) treatment adherence (≥80% of days covered by any AED); the first observed seizure defined the "breakthrough" seizure/index event. Treatment-adherent patients with epilepsy without any ER/hospital admission for seizures served as controls: an outpatient epilepsy-related medical claim within the selection window was chosen at random as the index date. The following were continuous enrollment requirements for all patients: ≥12-month pre- and ≥6-month postindex. Each case matched 1:1 to a control using propensity score matching. All-cause and epilepsy-related (epilepsy/convulsion diagnosis, AED pharmacy) resource utilization and unadjusted and adjusted direct health-care costs (per person, 2012 US dollars (USD)) were assessed in a 6-month follow-up period.

PRINCIPAL RESULTS

There were 5729 cases and 14,437 controls eligible. The final sample comprised 5279 matched case/control pairs. In unadjusted analyses, matched cases had significantly higher rates of all-cause hospitalization and ER visits compared to controls and significantly higher total all-cause direct health-care costs (median $12,714 vs. $5095, p<0.001) and total epilepsy-related costs among cases vs. controls (median $7293 vs. $1712, p<0.001), driven by higher inpatient costs. Among cases, costs increased with each subsequent seizure (driven by inpatient costs). Cases had 2.3 times higher adjusted all-cause costs and 8.1 times higher adjusted epilepsy-related costs than controls (both p<0.001).

CONCLUSION

Inpatient/ER-treated breakthrough seizures occurred among 28.4% of our treatment-adherent study sample and were associated with significant incremental health-care utilization and costs, primarily driven by hospitalizations. Our findings suggest the need for better seizure control via optimal patient management and the use of effective AED therapy, which can potentially lower health-care costs.

Cost-effectiveness of screening for HLA-A*31:01 prior to initiation of carbamazepine in epilepsy

OBJECTIVE

Carbamazepine causes severe cutaneous adverse drug reactions that may be predicted by the presence of the HLA-A*31:01 allele in northern European populations. There is uncertainty as to whether routine testing of patients with epilepsy is cost-effective. We conducted an economic evaluation of HLA-A*31:01 testing from the perspective of the National Health Service (NHS) in the United Kingdom.

METHODS

A short-term, decision analytic model was developed to estimate the outcomes and costs associated with a policy of routine testing (with lamotrigine prescribed for patients who test positive) versus the current standard of care, which is carbamazepine prescribed without testing. A Markov model was used to estimate total costs and quality-adjusted life-years (QALYs) over a lifetime to account for differences in drug effectiveness and the long-term consequences of adverse drug reactions.

RESULTS

Testing reduced the expected rate of cutaneous adverse drug reactions from 780 to 700 per 10,000 patients. The incremental cost-effectiveness ratio for pharmacogenetic testing versus standard care was £12,808 per QALY gained. The probability of testing being cost-effective at a threshold of £20,000 per QALY was 0.80, but the results were sensitive to estimated remission rates for alternative antiepileptic drugs (AEDs).

SIGNIFICANCE

Routine testing for HLA-A*31:01 in order to reduce the incidence of cutaneous adverse drug reactions in patients being prescribed carbamazepine for epilepsy is likely to represent a cost-effective use of health care resources.

Economic cost of treatment of childhood epilepsy in Enugu, southeast Nigeria

OBJECTIVES

The aim of this study was to determine the economic costs and the level of catastrophic health expenditure (CHE) due to childhood epilepsy.

METHODS

The study was conducted at the Paediatric Neurology Clinic of the University of Nigeria Teaching Hospital, Enugu. Data were collected using pre-tested questionnaires that were administered to caregivers of the children. The indirect and direct expenditure due to childhood epilepsy were computed. A 40 percent of monthly non-food expenditure was used to estimate CHE.

RESULTS

The average annual direct and indirect expenditures were USD 162.6 and USD 82.3, respectively. Most of direct costs were drugs (25.4 percent versus 35.3 percent) and investigations (48.7 percent versus 61.3 percent) for out-patient and in-patient, respectively. CHE was 34.1 percent and 63.6 percent for out-patient and in-patient care, respectively. The total annual costs: (direct and indirect), for childhood epilepsy of USD244.9. Considering the estimated 190,000 epileptic children in Nigeria, it will amount to USD46.53 million annually, approximately 0.018 percent of Nigeria Gross Domestic Product (GDP). All payments were made out-of-pocket with no health insurance for financial risk protection.

CONCLUSIONS

The cost of treatment of childhood epilepsy is high and catastrophic for many households. There was lack of usage of health financial risk mechanisms. Scale-up use of health financial risk protection mechanisms such as health insurance can reduce the economic burden.

The impact on health outcomes and healthcare utilisation of switching to generic medicines consequent to reference pricing: the case of lamotrigine in New Zealand

BACKGROUND

Many countries have implemented generic reference pricing and substitution as methods of containing pharmaceutical expenditure. However, resistance to switching between medicines is apparent, especially in the case of anti-epileptic medicines.

OBJECTIVES

This study sought to exploit a nation-wide policy intervention on generic reference pricing in New Zealand to evaluate the health outcomes of patients switching from originator to generic lamotrigine, an anti-epileptic medicine.

METHODS

A retrospective study using the national health collections and prescription records was conducted comparing patients who switched from originator brand to generic lamotrigine with patients who remained on the originator brand. Primary outcome measures included switch behaviour, changes in utilisation of healthcare services at emergency departments, hospitalisations and use of specialist services, and mortality.

RESULTS

Approximately one-quarter of all patients using the originator brand of lamotrigine switched to generic lamotrigine, half of whom made the switch within 60 days of the policy implementation. Multiple switches (three or more) between generic and brand products were evident for around 10% of switchers. Switch-back rates of 3% were apparent within 30 days post-switch. No difference in heath outcome measures was associated with switching from originator lamotrigine to a generic equivalent and hence no increased costs could be found for switchers.

CONCLUSIONS

Switching from brand to generic lamotrigine is largely devoid of adverse health outcomes; however, creating an incentive to ensure a greater proportion of patients switch to generic lamotrigine is required to achieve maximal financial savings from a policy of generic reference pricing.

Clinical- and cost-effectiveness of a nurse led self-management intervention to reduce emergency visits by people with epilepsy

People with chronic epilepsy (PWE) often make costly, and clinically unnecessary emergency department (ED) visits. Some do it frequently. No studies have examined interventions to reduce them. An intervention delivered by an epilepsy nurse specialist (ENS) might reduce visits. The rationale is it may optimize patients' self-management skills and knowledge of appropriate ED use. We examined such an intervention's clinical- and cost-effectiveness. Eighty-five adults with epilepsy were recruited from three London EDs with similar catchment populations. Forty-one PWE recruited from two EDs received treatment-as-usual (TAU) and formed the comparison group. The remaining 44 PWE were recruited from the ED of a hospital that had implemented a new ENS service for PWE attending ED. These participants formed the intervention group. They were offered 2 one-to-one sessions with an ENS, plus TAU. Participants completed questionnaires on health service use and psychosocial well-being at baseline, 6- and 12-month follow-up. Covariates were identified and adjustments made. Sixty-nine (81%) participants were retained at follow-up. No significant effect of the intervention on ED visits at 12 months or on other outcomes was found. However, due to less time as inpatients, the average service cost for intervention participants over follow-up was less than for TAU participants' (adjusted difference £558, 95% CI, -£2409, £648). Covariates most predictive of subsequent ED visits were patients' baseline feelings of stigmatization due to epilepsy and low confidence in managing epilepsy. The intervention did not lead to a reduction in ED use, but did not cost more, partly because those receiving the intervention had shorter hospital admissions. Our findings on long-term ED predictors clarifies what causes ED use, and suggests that future interventions might focus more on patients' perceptions of stigma and on their confidence in managing epilepsy. If addressed, ED visits might be reduced and efficiency-savings generated.

Neurofeedback treatment of epilepsy: from basic rationale to practical application

The treatment of epilepsy through operant conditioning of the sensorimotor rhythm electroencephalogram has a 35-year history. Neurophysiological studies have shown that this phasic oscillation reflects an inhibitory state of the sensorimotor system. Operant learning of sensory motor rhythm production results in an upregulation of excitation thresholds within the thalamocortical sensory and motor circuitry, which in turn is associated with reduced susceptibility to seizures. The clinical benefits derived from this neurofeedback training protocol, particularly in patients that are nonresponsive to pharmacotherapy, have been documented in many independent laboratories. Recent advances in computer technology have resulted in the availability of relatively inexpensive high-quality equipment for the application of neurofeedback therapy, thus presenting a viable and promising treatment alternative to the interested clinician.

Cost of epilepsy care in a Nigerian tertiary hospital

AIMS AND OBJECTIVES

The economic impact of epilepsy is enormous in terms of use of health care resources and loss of productivity. There is presently scanty data on economic impact of epilepsy in Nigeria,which necessitated this study.

SUBJECTS AND METHODS

This cross-sectional study is on epilepsy patients age e"16 years who attended Neurology clinic at UITH Ilorin. Data collected included clinical characteristics, utilisation of resources and cost of care. Direct medical costs included recurring costs like consultation, hospitalisation, medication and investigation fees. Indirect costs were number of days lost due to seizure attack and travelling to clinic by patients and relatives.

RESULTS

Sixty-five patients (32 males, 33 females) participated in the study with age range of 16 to 74 years and mean (SD) of 35 ± 17 years. Total clinic attendance was 314 days and 53 days were spent on admission. Close to 25 % of patients resided outside Ilorin metropolis and distance traveled to attend clinic varied from 4 to 200 km (mean=47 ± 30.6 km). The total annual cost per patient was 41, 878 ($279.2 USD). It consisted of direct cost [DC] of 33,616 (80%) and indirect cost [IC] of 8262 (20%). The three leading consumptive items in DC were: antiepileptic drugs (AEDs) - 24,138, investigations - 5373 and transportation - 2387. Majority (76.9%) of the patients were on carbamazepine. Self-estimated monthly family income varies from 3000 to 200,000 (median of 25,000). Only 23 patients (35.4%) bore the cost of care themselves. Of the IC, lost earnings due to absenteeism from work amounted to 6177. Equivalent of 1 USD was 150 at time of study. CONCLUSION. AEDs accounted for a significant proportion of TC. Increase in availability of generic drugs could help bring down the cost of care within affordable reach of indigent patients.

Epilepsy in Cambodia-treatment aspects and policy implications: a population-based representative survey

INTRODUCTION

We tested two treatment strategies to determine: treatment (a) prognosis (seizure frequency, mortality, suicide, and complications), (b) safety and adherence of treatment, (c) self-reported satisfaction with treatment and self-reported productivity, and policy aspects (a) number of required tablets for universal treatment (NRT), (b) cost of management, (c) manpower-gap and requirements for scaling-up of epilepsy care.

METHODS

We performed a random-cluster survey (N = 16510) and identified 96 cases (≥1 year of age) in 24 villages. They were screened by using a validated instrument and diagnosed by the neurologists. International guidelines were used for defining and classifying epilepsy. All were given phenobarbital or valproate (cost-free) in two manners patient's door-steps (March 2009-March 2010, primary-treatment-period, PTP) and treatment through health-centers (March 2010-June 2011, treatment-continuation-period, TCP). The emphasis was to start on a minimum dosage and regime, without any polytherapy, according to the age of the recipients. No titration was done. Seizure-frequency was monthly and self-reported.

RESULTS

The number of seizures reduced from 12.6 (pre-treatment) to 1.2 (end of PTP), following which there was an increase to 3.4 (end of TCP). Between start of PTP and end of TCP, >60.0% became and remained seizure-free. During TCP, ∼26.0% went to health centers to collect their treatment. Complications reduced from 12.5% to 4.2% between start and end of PTP and increased to 17.2% between start and end of TCP. Adverse events reduced from 46.8% to 16.6% between start and end of PTP. Nearly 33 million phenobarbital 100 mg tablets are needed in Cambodia.

CONCLUSIONS

Epilepsy responded sufficiently well to the conventional treatment, even when taken at a minimal dosage and a simple daily regimen, without any polytherapy. This is yet another confirmation that it is possible to substantially reduce direct burden of epilepsy through means that are currently available to us.

Patient and hospital characteristics are associated with cost of hospitalizations in children with epilepsy

We assessed patient and hospital characteristics and cost of hospitalizations in children with epilepsy, using the United States (U.S.) Kids' Inpatient Database (KID2009). There were 114,256 pediatric admissions for epilepsy in 2009. Admission rate was highest in those with the lowest household income. Private, urban teaching, and nonchildren's hospitals and hospitals in the Southern U.S. admitted the most patients. The average length of hospitalization was 5.4days, and adjusted cost was $6656/day of admission. The cost of hospitalizations was higher in those with the highest household income versus in those with lower income, private versus Medicare/Medicaid insurance, admissions to private versus public hospitals, urban teaching versus nonteaching or rural hospitals, and children's versus nonchildren's hospitals. Epilepsy comorbidities did not increase the cost of hospitalization. We found that the number and cost of hospitalizations in children with epilepsy vary by patient and hospital characteristics. Such findings are essential for informing future health plans and policy decisions on resource allocation.

Cost of epilepsy care in a Nigerian tertiary hospital

AIMS AND OBJECTIVES

The economic impact of epilepsy is enormous in terms of use of health care resources and loss of productivity. There is presently scanty data on economic impact of epilepsy in Nigeria,which necessitated this study.

SUBJECTS AND METHODS

This cross-sectional study is on epilepsy patients age e"16 years who attended Neurology clinic at UITH Ilorin. Data collected included clinical characteristics, utilisation of resources and cost of care. Direct medical costs included recurring costs like consultation, hospitalisation, medication and investigation fees. Indirect costs were number of days lost due to seizure attack and travelling to clinic by patients and relatives.

RESULTS

Sixty-five patients (32 males, 33 females) participated in the study with age range of 16 to 74 years and mean (SD) of 35±17 years. Total clinic attendance was 314 days and 53 days were spent on admission. Close to 25% of patients resided outside Ilorin metropolis and distance traveled to attend clinic varied from 4 to 200 km (mean=47±30.6 km). The total annual cost per patient was 41, 878 ($279.2 USD). It consisted of direct cost [DC] of 33,616 (80%) and indirect cost [IC] of 8262 (20%). The three leading consumptive items in DC were: antiepileptic drugs (AEDs)-24,138, investigations-5373 and transportation-2387. Majority (76.9%) of the patients were on carbamazepine. Self-estimated monthly family income varies from 3000 to 200,000 (median of 25,000). Only 23 patients (35.4%) bore the cost of care themselves. Of the IC, lost earnings due to absenteeism from work amounted to 6177. Equivalent of 1 USD was 150 at time of study.

CONCLUSION

AEDs accounted for a significant proportion of TC. Increase in availability of generic drugs could help bring down the cost of care within affordable reach of indigent patients.

[Survey of adults living with epilepsy in Hungary: health-related quality of life and costs]

BACKGROUND AND PURPOSE

Disease burden of epilepsy in Hungary is underexplored. The aim of our study was to assess the quality of life and costs of adults with epilepsy.

METHODS

Cross-sectional questionnaire survey was performed in two hospital based outpatient neurology centres involving consecutive patients with epilepsy. Demography, clinical characteristics, health status (EQ-5D) and health care utilisation in the past 12 months were surveyed. Cost calculation was performed from the societal perspective.

RESULTS

Altogether 100 patients (women 58%) were involved, their mean age was 37.6 (SD = 12.5) years. Disease duration was 15.0 (SD = 12.1) years on average and 22 (22%) patients were disability pensioners. The EQ-5D score was mean 0.83 (SD = 0.24) which is significantly lower than the age-matched population norm (p = 0.017). Pain/discomfort and anxiety/depression are the most problematic health dimensions. The annual cost per patient was mean 2421 (SD = 3249) Euros (679 397 SD = 911 783 HUF; conversion: 1 Euro = 280.6 HUF), distribution between direct medical, direct non-medical and indirect costs was 33%, 18% or 49%. Patients with seizure in the past 12 months have higher cost on avergare than the asymptomatic subsample (3119 vs. 988 Euros/patient/year; 935 481 vs. 277 209 HUF/patient/year).

CONCLUSION

Adults with epilepsy have significantly worse health status by the EQ-5D than the gender and age matched Hungarian general population. Disease related costs are significant especially in cases with seizure, productivity loss related costs are dominant. Our study provides basic data for clinical and sustainable health care financing decisions.

Incidence and prevalence of treated epilepsy among poor health and low-income Americans

OBJECTIVES

To determine the incidence and prevalence of treated epilepsy in an adult Medicaid population.

METHODS

We performed a retrospective, dynamic cohort analysis using Ohio Medicaid claims data between 1992 and 2006. Individuals aged 18-64 years were identified as prevalent cases if they had ≥2 claims of epilepsy (ICD-9-CM: 345.xx) or ≥3 claims of convulsion (ICD-9-CM: 780.3 or 780.39) and ≥2 claims of antiepileptic drugs. Incident cases were required to have no epilepsy or convulsion claims for ≥5 years before epilepsy diagnosis. Subjects were determined as having preexisting disability and/or comorbid conditions, including brain tumor, depression, developmental disorders, migraine, schizophrenia, stroke, and traumatic brain injury, when at least one of these conditions occurred before epilepsy onset.

RESULTS

There were 9,056 prevalent cases of treated epilepsy in 1992-2006 and 1,608 incident cases in 1997-2006. The prevalence was 13.2/1,000 (95% confidence interval, 13.0-13.5/1,000). The incidence was 362/100,000 person-years (95% confidence interval, 344-379/100,000 person-years). The incidence and prevalence were significantly higher in men, in older people, in blacks, and in people with preexisting disability and/or comorbid conditions. The most common preexisting conditions in epilepsy subjects were depression, developmental disorders, and stroke, whereas people with brain tumor, traumatic brain injury, and stroke had the higher risk of developing epilepsy.

CONCLUSIONS

The Medicaid population has a high incidence and prevalence of epilepsy, in an order of magnitude greater than that reported in the US general population. This indigent population carries a disproportionate amount of the epilepsy burden and deserves more attention for its health care needs and support services.

[Healthcare management of an epilepsy clinic: factors involved in the demand for health care and clinical situation of patients]

INTRODUCTION

Epilepsy is a chronic illness that requires a long-term periodic follow-up of the patient and this means that as time goes by the number of patients attended increases, with the ensuing added cost for the healthcare system.

AIM

To determine the factors involved in the time until an epileptic patient's next visit.

PATIENTS AND METHODS

Our sample consisted of a selection of patients who visited the epilepsy clinic at our hospital consecutively during one year. Their clinical situation and relationship with the medical advice they were given, together with the factors involved in the time elapsed until the next visit, were analysed by means of predictive econometric models.

RESULTS

There is a clear association between the patient's clinical situation and the modification of the treatment proposed by the neurologist in the previous visit. The factors involved in the time until the next visit were the frequency of seizures, adverse side effects from medicines -above all those that affect cognition- and the medical advice given to the patient. Polytherapy, psychoaffective disorders or the patient's social situation were not found to be significant.

CONCLUSIONS

Follow-up visits in a specific epilepsy clinic improves the patient's situation. This is the first analysis of the demand for healthcare in patients with epilepsy conducted by means of econometric methods and from a mixed physician-patient perspective. Since the factors that determine the time until the next visit can be modified, the number of visits per year could be reduced, thus improving patients' clinical situation. We suggest a greater amount of time should be spent per visit so as to be able to have a bearing on it and thereby cut costs in the long term.

Epilepsy in Sweden: health care costs and loss of productivity--a register-based approach

PURPOSE

The objective was to estimate health care costs and productivity losses due to epilepsy in Sweden and to compare these estimates to previously published estimates.

METHODS

Register data on health care utilisation, pharmaceutical sales, permanent disability and mortality were used to calculate health care costs and costs that accrue due to productivity losses. By linkage of register information, we were able to distinguish pharmaceuticals prescribed against epilepsy from prescriptions that were prompted by other indications.

RESULTS

The estimated total cost of epilepsy in Sweden in 2009 was <euro>441 million, which corresponds to an annual per-patient cost of <euro>8,275. Health care accounted for about 16% of the estimated total cost, and drug costs accounted for about 7% of the total cost. The estimated health care cost corresponded to about 0.2% of the total health care cost in Sweden in 2009. Indirect costs were estimated at <euro>370 million, 84% of which was due to sickness absenteeism. Costs resulting from epilepsy-attributable premature deaths or permanent disability to work accounted for about 1% of the total indirect cost in Sweden in 2009.

DISCUSSION

The per-patient cost of epilepsy is substantial. Thus, even though the prevalence of the illness is relatively small, the aggregated cost that epilepsy incurs on society is significant.

[Economic burden of disease studies in patients with epilepsy]

OBJECTIVE

To analyze the various factors affecting the economic burden of disease in patients with epilepsy.

METHODS

This research used a multi-stage random sampling method, comprehensive intervention and without intervention of the epilepsy project group conducted a field survey of health examination among patients with epilepsy of 874 (422 cases in intervention group and 452 cases in control group) in Mengzhou, Xiuwu, Yancheng, Yuanhui, Wuyang, Linying, Shaoling, Xinye and Fangcheng. DALY indicators combined with human capital approach was used to measure the economic burden of disease in patients from two aspects of the direct economic burden and indirect economic burden.

RESULTS

The age of comprehensive intervention group was (43.7 ± 8.5) years old, and it was (44.4 ± 7.2) years old in no intervention control group. The age difference was not statistically significant (P = 0.365). The direct economic burden per capita of the survey was 1019.6 yuan per year, while epilepsy drugs 434.2 yuan per year, 485.2 and 66.4 yuan per year in the intervention group, while 1518.5 and 777.5 yuan per year in the control group. Each object in this study lost (16.67 ± 10.01) DALY, with 8.58 DALY in intervention group and 24.23 DALY in no intervention control group. The per capita indirect economic burden of the intervention and control groups were 68 115.2, 401 036.5 yuan, the per capita total economic burden of disease were 68 600.5, 408 755.0 yuan. Multivariate logistic regression analysis showed that disease duration year of ≥ 37, 30 - 36, 20 - 29, 10 - 19, OR (95%CI) were 4.44 (2.37 - 8.33), 3.32 (1.85 - 5.94), 3.25 (1.90 - 5.56), 2.53 (1.46 - 4.41). If patients with longer duration, the more serious the patient's disease burden. Medication compliance (in order to comply with a good group control) OR (95%CI) was 3.37 (2.34 - 4.83), medication in the single form (serving multi-drug groups for control) OR (95%CI) 0.41 (0.29 - 0.59). Serving a single agent and good compliance of economic burden of disease were lighter.

CONCLUSION

Epilepsy caused serious economic damage. Longer duration, medication adherence poor and serving more than medicine by heavier economic burden of disease; comprehensive intervention could reduce the economic burden of disease of patients with epilepsy.

Health plan paid cost of epilepsy in 2009 in the U.S

Our objectives were to estimate the health plan paid cost of epilepsy and to show major cost driver(s) of these costs. The health insurance claims and membership data from six U.S. health plans were analyzed. To prepare two comparison groups, individuals with epilepsy (n=5810) were match-paired with individuals without epilepsy (n=5810) using propensity scores derived from logistic regression using gender, age group, health plan product, and length of enrollment in the health plans. Total health plan paid cost per member per year (PMPY) was $11,232 for the epilepsy group and $3026 for the controls (p<0.001). The estimated cost PMPY for treatment of epilepsy was $8206. Relative distribution (%) of health plan paid costs ($) by cost driver category based on place of service (POS) indicated that the treatment of epilepsy places a larger cost burden in inpatient POS than in outpatient hospital or MD office POS compared to controls.

[Cost-utility analysis of comprehensive intervention on epilepsy]

OBJECTIVE

To discuss the cost-utility regarding the effect of comprehensive intervention program on epilepsy.

METHODS

874 cases with epilepsy were investigated in 9 pilot sites in Henan province. Cost of epilepsy comprehensive intervention was calculated based on the research projects of epilepsy prevention and management of rural areas. Disability-adjusted life year (DALY) and quality adjusted life year (QALY) were used as utility index for cost-utility analysis.

RESULTS

Of the 874 cases, 8.58 DALY was lost and 27.95 QALY was obtained per capita in the intervention group (422 cases). The costs per QALY and DALY obtained were 2454.10 and 7995.40 Yuan, respectively. Relative to the non-intervention control group (452 cases), the costs for QALY obtained by the intervention group had reduced. The investment would reduce 21 735.10 Yuan when each additional DALY was saved.

CONCLUSION

Epilepsy caused serious economic burden to the society, families and the patients themselves. Comprehensive intervention program could reduce the economic burden of the disease thus yielding high cost-benefit. This program was deserved to be promoted.

Epilepsy, poverty and early under-nutrition in rural Ethiopia

PURPOSE

The incidence of epilepsy in Ethiopia is high compared with industrialised countries, but in most cases the cause of epilepsy is unknown. Childhood malnutrition remains widespread. We performed a case-control study to determine whether epilepsy is associated with poverty and markers of early under-nutrition.

METHODS

Patients with epilepsy (n=112), aged 18-45years, were recruited from epilepsy clinics in and around two towns in Ethiopia. Controls with a similar age and gender distribution (n=149) were recruited from patients and relatives attending general outpatient clinics. We administered a questionnaire to define the medical and social history of cases and controls, and then performed a series of anthropometric measurements. Unconditional logistic regression was used to estimate multivariate adjusted odds ratios. Multiple linear regression was used to estimate adjusted case-control differences for continuously distributed outcomes.

RESULTS

Epilepsy was associated with illiteracy/low levels of education, odds ratio=3.0 (95% confidence interval: 1.7-5.6), subsistence farming, odds ratio=2.6 (1.2-5.6) and markers of poverty including poorer access to sanitation (p=0.009), greater overcrowding (p=0.008) and fewer possessions (p<0.001). Epilepsy was also associated with the father's death during childhood, odds ratio=2.2 (1.0-4.6). Body mass index was similar in cases and controls, but patients with epilepsy were shorter and lighter with reduced sitting height (p<0.001), bitrochanteric diameter (p=0.029) and hip size (p=0.003). Patients with epilepsy also had lower mid-upper arm circumference (p=0.011) and lean body mass (p=0.037).

CONCLUSION

Epilepsy in Ethiopia is strongly associated with poor education and markers of poverty. Patients with epilepsy also had evidence of stunting and disproportionate skeletal growth, raising the possibility of a link between early under-nutrition and epilepsy.

Prevalence of treated epilepsy in Korea based on national health insurance data

The Korean national health security system covers the entire population and all medical facilities. We aimed to estimate epilepsy prevalence, anticonvulsant utilization pattern and the cost. We identified prevalent epilepsy patients by the prescription of anticonvulsants under the diagnostic codes suggesting seizure or epilepsy from 2007 Korean National Health Insurance databases. The information of demography, residential area, the kind of medical security service reflecting economic status, anticonvulsants, and the costs was extracted. The overall prevalence of treated epilepsy patients was 2.41/1,000, and higher for men than women. The age-specific prevalence was the lowest in those in their thirties and forties. Epilepsy was more prevalent among lower-income individuals receiving medical aid. The regional prevalence was the highest in Jeju Island and lowest in Ulsan city. New anticonvulsants were more frequently used than old anticonvulsants in the younger age group. The total annual cost of epilepsy or seizure reached 0.46% of total medical expenditure and 0.27% of total expenditure on health. This is the first nationwide epidemiological report issued on epilepsy in Korea. Epilepsy prevalence in Korea is comparable to those in developed countries. Economic status and geography affect the prevalence of epilepsy.