Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA.
Department of Neurology, The Ohio State University, Columbus, Ohio, USA.
Epilepsia Open. 2023 Sep;8(3):1096-1110. doi: 10.1002/epi4.12789. Epub 2023 Jul 22.
For people with drug-resistant epilepsy, the use of epilepsy surgery is low despite favorable odds of seizure freedom. To better understand surgery utilization, we explored factors associated with inpatient long-term EEG monitoring (LTM), the first step of the presurgical pathway.
Using 2001-2018 Medicare files, we identified patients with incident drug-resistant epilepsy using validated criteria of ≥2 distinct antiseizure medication (ASM) prescriptions and ≥1 drug-resistant epilepsy encounter among patients with ≥2 years pre- and ≥1 year post-diagnosis Medicare enrollment. We used multilevel logistic regression to evaluate associations between LTM and patient, provider, and geographic factors. We then analyzed neurologist-diagnosed patients to further evaluate provider/environmental characteristics.
Of 12 044 patients with incident drug-resistant epilepsy diagnosis identified, 2% underwent surgery. Most (68%) were diagnosed by a neurologist. In total, 19% underwent LTM near/after drug-resistant epilepsy diagnosis; another 4% only underwent LTM much prior to diagnosis. Patient factors most strongly predicting LTM were age <65 (adjusted odds ratio 1.5 [95% confidence interval 1.3-1.8]), focal epilepsy (1.6 [1.4-1.9]), psychogenic non-epileptic spells diagnosis (1.6 [1.1-2.5]) prior hospitalization (1.7, [1.5-2]), and epilepsy center proximity (1.6 [1.3-1.9]). Additional predictors included female gender, Medicare/Medicaid non-dual eligibility, certain comorbidities, physician specialties, regional neurologist density, and prior LTM. Among neurologist-diagnosed patients, neurologist <10 years from graduation, near an epilepsy center, or epilepsy-specialized increased LTM likelihood (1.5 [1.3-1.9], 2.1 [1.8-2.5], 2.6 [2.1-3.1], respectively). In this model, 37% of variation in LTM completion near/after diagnosis was explained by individual neurologist practice and/or environment rather than measurable patient factors (intraclass correlation coefficient 0.37).
A small proportion of Medicare beneficiaries with drug-resistant epilepsy completed LTM, a proxy for epilepsy surgery referral. While some patient factors and access measures predicted LTM, non-patient factors explained a sizable proportion of variance in LTM completion. To increase surgery utilization, these data suggest initiatives targeting better support of neurologist referral.
对于耐药性癫痫患者，尽管有较高的癫痫无发作几率，但癫痫手术的使用率仍然较低。为了更好地了解手术的应用情况，我们探讨了与住院长程脑电图监测（LTM）相关的因素，LTM 是术前评估的第一步。
我们使用 2001 年至 2018 年的医疗保险记录，通过验证的标准（≥2 种不同的抗癫痫药物（ASM）处方和≥1 种耐药性癫痫发作）识别出患有新发耐药性癫痫的患者，并对具有≥2 年预诊断和≥1 年诊断后医疗保险登记的患者进行耐药性癫痫发作的评估。我们使用多水平逻辑回归来评估 LTM 与患者、提供者和地理因素之间的关系。然后，我们分析了由神经科医生诊断的患者，以进一步评估提供者/环境特征。
在确定的 12044 例新发耐药性癫痫患者中，有 2%接受了手术治疗。其中大多数（68%）由神经科医生诊断。总体而言，有 19%的患者在耐药性癫痫诊断后/后不久接受了 LTM；另有 4%的患者仅在诊断前很久就接受了 LTM。预测 LTM 最强烈的患者因素是年龄<65 岁（校正优势比 1.5[95%置信区间 1.3-1.8]）、局灶性癫痫（1.6[1.4-1.9]）、癫痫中心附近（1.6[1.3-1.9]）。其他预测因素包括女性、医疗保险/医疗补助非双重资格、某些合并症、医生专业、区域神经科医生密度和既往 LTM。在由神经科医生诊断的患者中，毕业时间<10 年的神经科医生、靠近癫痫中心或癫痫专科的神经科医生更有可能进行 LTM（1.5[1.3-1.9]、2.1[1.8-2.5]、2.6[2.1-3.1]）。在该模型中，解释 LTM 完成率个体神经科医生实践和/或环境而非可测量的患者因素（组内相关系数 0.37）的差异占 37%。
一小部分患有耐药性癫痫的医疗保险受益患者完成了 LTM，这是癫痫手术转诊的代表。虽然一些患者因素和获得措施预测了 LTM，但非患者因素解释了 LTM 完成率的很大一部分差异。为了提高手术使用率，这些数据表明需要采取措施，以更好地支持神经科医生的转诊。
