Researchers Find Racial Disparities in Care for Epilepsy at Hospitals

Neurology Today
6 January 2011; Volume 11(1); p 1, 7

Samson, Kurt

There appear to be significant racial and ethnic differences in the ways that individuals with seizures seek and receive treatment in emergency departments, researchers reported at the annual American Epilepsy Society meeting in San Antonio, TX, in December.

WHY FEWER BLACKS with epilepsy receive neuroimaging is one of the questions raised by a new study.

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An analysis by investigators at Brigham and Women's Hospital in Boston found that blacks and Hispanics were less likely to receive neuroimaging or to be admitted to the hospital when seen in their tertiary care emergency department (ED) for an epileptic seizure.

Katherine Gleason and senior author Barbara Dworetzky MD, chief of the Division of Epilepsy, EEG and Sleep Neurology, and director of Brigham and Women's EEG Laboratory in the Edward B. Bromfield Epilepsy Program, reviewed one year's worth of records for all ED visits coded for epilepsy, seizures, myoclonus, and convulsions, but only included visits clearly precipitated by a seizure. They then compared race, insurance status, and admission rates, frequency of ED visits in the year, probable cause of seizure, and ED management, including lab results, neuroimaging, and medication management.

Of a total of 559 visits for seizure made by 442 patients — 1.5 percent of all ED visits — 39 percent were by non-whites, including 100 blacks and 59 Hispanics.

Non-whites were more likely to have a history of epilepsy (p=0.01) and have multiple ED visits for seizure within the year (p=0.001). There was also a noticeable trend toward less neuroimaging in minority patients (p=.02), researchers told reporters at a press briefing.

Regardless of race or insurance status, all patients were equally likely to have received lab testing, including electrolytes and serum or urine toxicology screening, as well as receiving antiepileptic drugs (AEDs).

While all of the patients were also equally likely to present for seizure without a clear cause, non-whites were more likely to have evidence of non-adherence to their medication regimen, that is, they missed or ran out of AEDs.

Aside from the admission rate, the most noticeable difference between races was observed in repeated ED visits, the researchers said.

“Now we have the data and need to look more at these differences in race and the high rate of patients with epilepsy using the ED,” Gleason noted. “While non-adherence to AEDs was higher in the minority patients, only one of nearly 600 patients came in explicitly for a new prescription; all the rest had seizures and were brought in for care.”

It is possible that blacks, in particular, are using the ED for their regular epilepsy care rather than relying on a primary care physician, Dr. Dworetzky added, something she said needs to be further studied.

“The ED could be a good place to provide education emphasizing the need for better adherence to seizure medication,” she said. “If we can just get these patients from missing their drugs we might be able to prevent them from ending up in hospital emergency departments so often.”

“This paper provides additional empirical evidence of these racial disparities, especially with regard to access to medical technology. But it also shows that hospitals may work up these patients differently, so the question is why?” said Ronnie D. Horner, PhD, professor of neurology and chair of the Department of Public Health Sciences at the University of Cincinnati (UC), in a telephone interview with Neurology Today.

Dr. Horner, who served as director of the health disparities research program at the NINDS before joining the UC faculty in 2004, said if many of these patients had been in before for epileptic seizures, the emergency room doctors may have decided that diagnostic imaging and hospitalization was unnecessary.

“It may be that many of the patients have been in the hospital before, maybe a number of times over the years, and it is clear that their seizures are caused by not taking their AEDs.”

Nonetheless, he found it “interesting” that most privately insured patients received imaging in the study.

He and his colleague, Magda Szaflarski, PhD, assistant professor in the UC Department of Public Health Sciences, co-authored a 2006 paper in Epilepsy & Behavior examining racial disparities in which they too found minorities had less utilization or access to state-of-the-art therapies, as well as limited knowledge about epilepsy and treatment and other factors that may impede treatment and compliance.

Dr. Szaflarski told Neurology Today that there have been three systematic review studies in the last four years, including their own, that have documented these differences,

“What is interesting about the new paper is that it is the first large-scale study to point out disparities in neuroimaging in these patients,” she said. “One of the study's limitations is that while neuroimaging is considered standard-of-care for new seizure patients, patients with a history of epilepsy typically do not require imaging and the data do not appear to have discriminated between the two groups.”

In other respects, however, they called the data “solid and robust.”

DR. MAGDA SZAFLARSKI: “What is interesting about the new paper is that it is the first large-scale study to point out disparities in neuroimaging in these patients.”

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Differences in minority patient work-up and management can also reflect provider bias, according to Dr. Horner, while non-adherence can result from many factors, including economic issues, mistrust of physicians, and cultural beliefs about the medications. Moreover, other studies have suggested that minorities tend to be seen more often at facilities lacking resources for state-of-the-art care, he told Neurology Today.

Consistent findings of treatment disparities in minorities with epilepsy is starting to raise awareness that the gap must be bridged, and the process of care is showing signs of beginning to change, Dr. Szaflarski said.

“The field is quickly moving forward looking into these differences,” added Dr. Horner. “Now we have reached the next step: how to address them. In terms of non-adherence to medication, we need to determine whether it is the cost or the side effects or some other reason? One place to begin is by asking the patients. If we are going to make non-adherence with AEDs a non-issue, we need to know why patients are not taking their meds.

BY KURT SAMSON

Even in patients with Medicaid, many fail to adhere to their antiepileptic drug (AED) regimen, according to a study in which investigators examined the clinical and economic costs of treated and untreated epilepsy using a database of Medicaid patients who should not have had difficulty adhering to prescribed AED regimens because their prescriptions were covered. The data were described at a news briefing at the American Epilepsy Society annual meeting.

Ranjani Manjunath, a health outcomes researcher specializing in epilepsy at GlaxoSmithKline, Research Triangle Park, NC, and Edward Faught, MD, professor of neurology at Emory University in Atlanta, told reporters that uncontrolled epilepsy was associated with significantly greater resource utilization and higher rates of negative outcomes.

Uncontrolled epilepsy was defined as two consecutive changes in AED therapy 30 days apart, followed by one epilepsy-related inpatient or ED visit within the next 365 days.

A total of 3,562 patients with uncontrolled epilepsy were identified, as well as 3,318 well controlled, and 3,560 intermediate patients. Compared to well-controlled epilepsy patients, those with uncontrolled epilepsy had significantly higher all-cause hospitalizations rates (1.4 vs. 0.2 visits/patient-year), longer hospital stays (9.7 vs. 1.5 days/patient-year), more frequent emergency-room visits (4.1 vs. 1.1 visits/patient-year), and more neurologist visits (0.7 vs. 0.2 visits/patient-year).

“Untreated patients used EDs two times more often than those with controlled epilepsy,” Manjunath said. “They had 10 times more status epilepticus episodes and three times more emergency room visits and/or neurologist consults.”

RANJANI MANJUNATH: “Untreated patients used EDs two times more often than those with controlled epilepsy,” Manjunath said. “They had 10 times more status epilepticus episodes and three times more emergency room visits and/or neurologist consults.”

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The problem is probabIy much bigger that the study suggests, she told reporters at a news briefing. “I think the major limitation of our study is that it may underestimate the economic and clincal burden.”

Szaflarski M, Szaflarski JP, Horner R, et al. Racial/ethnic disparities in the treatment of epilepsy: What do we know? What do we need to know? 2006;9: 243-264.