目标:对于耐药癫痫患者,使用癫痫手术是低,尽管有利的机会的癫痫发作的自由。为了更好地了解手术的使用,我们探讨了与住院患者长期脑电图监测(LTM)相关的因素,术前途径的第一步。
方法:使用2001-2018年的医疗保险文件,我们在Medicare纳入诊断前>2年和诊断后>1年的患者中,使用>2种不同的抗癫痫药物(ASM)处方和>1种耐药癫痫的经验证标准,确定了发生耐药癫痫的患者.我们使用多水平逻辑回归来评估LTM和患者之间的关联,提供者,和地理因素。然后,我们分析了神经科医生诊断的患者,以进一步评估提供者/环境特征。
结果:在12,044名诊断为耐药癫痫的患者中,2%进行了手术。大多数(68%)是由神经科医生诊断的。总的来说,19%的人在耐药性癫痫诊断前后接受了LTM;另外4%的人在诊断前仅接受了LTM。最能预测LTM的患者因素是年龄<65(调整后比值比1.5[95%置信区间1.3-1.8]),局灶性癫痫(1.6[1.4-1.9]),精神性非癫痫法术诊断(1.6[1.1-2.5])住院前(1.7,[1.5-2]),和癫痫中心接近(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,专科医师,区域神经科医生密度,和先前的LTM。在神经科医生诊断的患者中,神经科医生毕业后<10年,在癫痫中心附近,或癫痫特化的LTM可能性增加(1.5[1.3-1.9],2.1[1.8-2.5]、2.6[2.1-3.1],分别)。在这个模型中,诊断前后LTM完成变化的37%是由个体神经科医生实践和/或环境解释的,而不是可测量的患者因素(组内相关系数0.37)。
结论:一小部分患有耐药性癫痫的医疗保险受益人完成了LTM,癫痫手术转诊的代理人。虽然一些患者因素和访问措施预测了LTM,非患者因素解释了LTM完成中相当大比例的方差.为了提高手术利用率,这些数据表明旨在更好地支持神经科医师转诊的举措.
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.