Edward Faught

Nonadherence to antiepileptic drugs and increased mortality Findings from the RANSOM Study

Objectives: The primary objective was to investigate whether nonadherence to antiepileptic drugs (AEDs) is associated with increased mortality and the secondary objective to examine whether nonadherence increases the risk of serious clinical events, including emergency department (ED) visits, hospitalizations, motor vehicle accident (MVA) injuries, fractures, and head injuries. Methods: A retrospective open-cohort design was employed using Medicaid claims data from Florida, Iowa, and New Jersey from January 1997 through June 2006. Patients aged ≥18 years with ≥1 diagnosis of epilepsy by a neurologist and ≥2 AED pharmacy dispensings were selected. Medication possession ratio (MPR) was used to evaluate AED adherence on a quarterly basis with MPR ≥0.80 considered adherent and <0.80 nonadherent. The association of nonadherence with mortality was assessed using a time-varying Cox regression model adjusting for demographic and clinical confounders. Incidence rates for serious clinical events were compared between adherent and nonadherent quarters using incidence rate ratios (IRRs) with 95% CIs calculated based on the Poisson distribution. Results: The 33,658 study patients contributed 388,564 AED-treated quarters (26% nonadherent). Nonadherence was associated with an over threefold increased risk of mortality compared to adherence (hazard ratio = 3.32, 95% CI = 3.11–3.54) after multivariate adjustments. Time periods of nonadherence were also associated with a significantly higher incidence of ED visits (IRR = 1.50, 95% CI = 1.49–1.52), hospital admissions (IRR = 1.86, 95% CI = 1.84–1.88), MVA injuries (IRR = 2.08, 95% CI = 1.81–2.39), and fractures (IRR = 1.21, 95% CI = 1.18–1.23) than periods of adherence. Conclusion: These findings suggest that nonadherence to antiepileptic drugs can have serious or fatal consequences for patients with epilepsy.

Cerebral complications of angiography for transient ischemia and stroke Prediction of risk

We examined the records of 147 consecutive patients studied by femoral catheterization to identify factors contributing to angiographic risk in cerebrovascular disease. Cerebral complications occurred in 12.2 percent and were permanent in 5.2 percent. Computer-assisted multivariate analysis of 21 possible risk factors was done. Two of these risk factors correlated strongly with increased risk: number of previous transient ischemic attacks (TIAs) (p < 0.001), and the presence of arterial stenosis of greater than 90 percent (p < 0.03). Risk factors of marginal significance were: diabetes, female sex, and number of selective injections. A discriminant function for estimation of risk was derived: D = [8 × number of TIAs] + [6 × number of arteries catheterized] + [14 if diabetic, 0 if not] + [11 if female, 0 if male]. When D was > 55, 77 percent of patients had a complication. When D was < 55, 98 percent of patients had no complication. Unfortunately, patients in whom the study is most indicated tend to be those at greatest risk.

Incidence and prevalence of epilepsy among older US Medicare beneficiaries

Objective: To determine the prevalence and incidence of epilepsy among US Medicare beneficiaries aged 65 years old and over, and to compare rates across demographic groups. Methods: We performed a retrospective analysis of Medicare administrative claims for 2001–2005, defining prevalent cases as persons with ≥1 claim with diagnosis code 345.xx (epilepsy) or 2 or more with diagnosis code 780.3x (convulsion) ≥1 month apart, and incident cases as prevalent cases with 2 years immediately before diagnosis without such claims. Prevalence and incidence rates were calculated for the years 2003–2005 using denominators estimated from a 5% random sample of Medicare beneficiaries. Results were correlated with gender, age, and race. Results: We identified 282,661 per year on average during 2001–2005 (a total of 704,243 unique cases overall), and 62,182 incident cases per year on average during 2003–2005. Average annual prevalence and incidence rates were 10.8/1,000 and 2.4/1,000. Overall, rates were higher for black beneficiaries (prevalence 18.7/1,000, incidence 4.1/1,000), and lower for Asians (5.5/1,000, 1.6/1,000) and Native Americans (7.7/1,000, 1.1/1,000) than for white beneficiaries (10.2/1,000, 2.3/1,000). Incidence rates were slightly higher for women than for men, and increased with age for all gender and race groups. Conclusions: Epilepsy is a significant public health problem among Medicare beneficiaries. Efforts are necessary to target groups at higher risk, such as minorities or the very old, and to provide the care necessary to reduce the negative effects of epilepsy on quality of life.

Ambulatory EEG monitoring.

Advances in computer technology offer increased capabilities for ambulatory EEG monitoring. The technical specifications of currently available ambulatory EEG machines reasonably approximate inpatient EEG equipment. However, the evolution of ambulatory EEG from 3-channel analog cassette recordings to reformatable 32-channel digital devices with computer-assisted spike and seizure detection raises several unresolved issues. Should patients with nondiagnostic routine EEG receive ambulatory EEG? Is ambulatory EEG as accurate for patients with unclear clinical diagnoses as inpatient video-EEG monitoring? If the diagnostic yield of ambulatory EEG is less than inpatient monitoring, do outpatient savings still make the technique cost-effective? This article reviews the development of ambulatory EEG and the investigations of its clinical utility. An evidence-based analysis explores the benefits and limitations of ambulatory EEG, and offers aspects of its use which require additional clinical research.

Adherence to antiepilepsy drug therapy

Adherence to antiepilepsy drug (AED) therapy is critical for effective disease management, yet adherence and persistence rates are low due to several barriers. The definitions of adherence (80% rate of total pills taken, medication possession ratio, and days covered by prescriptions filled) and methods of measurement (patient self-reports, serum drug levels, pill counts, electronic bottle tops, and reviews of pharmacy records) are not without limitations, and their applicability to epilepsy is not clear. The use of simple adherence scales during office visits can provide an overall impression of a patients adherence and can serve as a basis for practitioner-patient dialog. Efforts to improve adherence should focus on provider and healthcare system determinants versus those focused only on the patient. These interventions include non-judgmental communication, patient education, simplification of the dosage regimen with once-daily therapies, and the use of patient reminders.

Long‐term safety and efficacy in patients with uncontrolled partial‐onset seizures treated with adjunctive lacosamide: Results from a phase III open‐label extension trial

Purpose:  To evaluate the long‐term (up to 5 years exposure) safety and efficacy of lacosamide as adjunctive therapy in patients with uncontrolled partial‐onset seizures taking one to three concomitant antiepileptic drugs (AEDs) in open‐label extension trial SP756 (NCT00522275).

Cognitive Functioning in Community Dwelling Older Adults with Chronic Partial Epilepsy

Summary:  Purpose: To examine cognitive functioning in community‐dwelling older adults with chronic partial epilepsy and demographically matched healthy older adults.

Burden of uncontrolled epilepsy in patients requiring an emergency room visit or hospitalization

Objective: To quantify the clinical and economic burden of uncontrolled epilepsy in patients requiring emergency department (ED) visit or hospitalization. Methods: Health insurance claims from a 5-state Medicaid database (1997Q1–2009Q2) and 55 self-insured US companies (“employer,” 1999Q1 and 2008Q4) were analyzed. Adult patients with epilepsy receiving antiepileptic drugs (AED) were selected. Using a retrospective matched-cohort design, patients were categorized into cohorts of “uncontrolled” (≥2 changes in AED therapy, then ≥1 epilepsy-related ED visit/hospitalization within 1 year) and “well-controlled” (no AED change, no epilepsy-related ED visit/hospitalization) epilepsy. Matched cohorts were compared for health care resource utilization and costs using multivariate conditional regression models and nonparametric methods. Results: From 110,312 (Medicaid) and 36,529 (employer) eligible patients, 3,454 and 602 with uncontrolled epilepsy were matched 1:1 to patients with well-controlled epilepsy, respectively. In both populations, uncontrolled epilepsy cohorts presented about 2 times more fractures and head injuries (all p values < 0.0001) and higher health care resource utilization (ranges of adjusted incidence rate ratios [IRRs] [all-cause utilization]: AEDs = 1.8–1.9, non-AEDs = 1.3–1.5, hospitalizations = 5.4–6.7, length of hospital stays = 7.3–7.7, ED visits = 3.7–5.0, outpatient visits = 1.4–1.7, neurologist visits = 2.3–3.1; all p values < 0.0001) than well-controlled groups. Total direct health care costs were higher in patients with uncontrolled epilepsy (adjusted cost difference [95% confidence interval (CI)] Medicaid =

Clinical and economic impact of vagus nerve stimulation therapy in patients with drug-resistant epilepsy☆

12,258 [

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

10,482–