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Di Gennaro G, Lattanzi S, Mecarelli O, Saverio Mennini F, Vigevano F. Current challenges in focal epilepsy treatment: An Italian Delphi consensus. Epilepsy Behav 2024; 155:109796. [PMID: 38643659 DOI: 10.1016/j.yebeh.2024.109796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/18/2024] [Accepted: 04/14/2024] [Indexed: 04/23/2024]
Abstract
BACKGROUND Epilepsy, a globally prevalent neurological condition, presents distinct challenges in management, particularly for focal-onset types. This study aimed at addressing the current challenges and perspectives in focal epilepsy management, with focus on the Italian reality. METHODS Using the Delphi methodology, this research collected and analyzed the level of consensus of a panel of Italian epilepsy experts on key aspects of focal epilepsy care. Areas of focus included patient flow, treatment pathways, controlled versus uncontrolled epilepsy, follow-up protocols, and the relevance of patient-reported outcomes (PROs). This method allowed for a comprehensive assessment of consensus and divergences in clinical opinions and practices. RESULTS The study achieved consensus on 23 out of 26 statements, with three items failing to reach a consensus. There was strong agreement on the importance of timely intervention, individualized treatment plans, regular follow-ups at Epilepsy Centers, and the role of PROs in clinical practice. In cases of uncontrolled focal epilepsy, there was a clear inclination to pursue alternative treatment options following the failure of two previous therapies. Divergent views were evident on the inclusion of epilepsy surgery in treatment for uncontrolled epilepsy and the routine necessity of EEG evaluations in follow-ups. Other key findings included concerns about the lack of pediatric-specific research limiting current therapeutic options in this patient population, insufficient attention to the transition from pediatric to adult care, and need for improved communication. The results highlighted the complexities in managing epilepsy, with broad consensus on patient care aspects, yet notable divergences in specific treatment and management approaches. CONCLUSION The study offered valuable insights into the current state and complexities of managing focal-onset epilepsy. It highlighted many deficiencies in the therapeutic pathway of focal-onset epilepsy in the Italian reality, while it also underscored the importance of patient-centric care, the necessity of early and appropriate intervention, and individualized treatment approaches. The findings also called for continued research, policy development, and healthcare system improvements to enhance epilepsy management, highlighting the ongoing need for tailored healthcare solutions in this evolving field.
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Affiliation(s)
| | - Simona Lattanzi
- Neurological Clinic, Department of Experimental and Clinical Medicine, Marche Polytechnic University, Ancona, Italy
| | - Oriano Mecarelli
- Department of Human Neurosciences, Sapienza University, Rome (Retired) and Past President of LICE, Italian League Against Epilepsy, Rome, Italy
| | - Francesco Saverio Mennini
- Faculty of Economics, Economic Evaluation and HTA (EEHTA), CEIS, University of Rome "Tor Vergata", Rome, Italy; Institute for Leadership and Management in Health, Kingston University London, London, UK.
| | - Federico Vigevano
- Head of Paediatric Neurorehabilitation Department, IRCCS San Raffaele, Rome, Italy.
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Burani M, Giovannini G, Pugnaghi M, Orlandi N, Cioclu MC, Vaudano AE, Moriconi E, Pavesi G, Meletti S. The Epilepsy Surgery Satisfaction Questionnaire (ESSQ-19): Italian language translation and validation. Neurol Sci 2024; 45:2835-2843. [PMID: 38217788 DOI: 10.1007/s10072-024-07327-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/09/2024] [Indexed: 01/15/2024]
Abstract
OBJECTIVE Epilepsy surgery can be proposed as a treatment option in people with focal epilepsy, however satisfaction with epilepsy surgery in Italy remains unknown. We aimed to validate in Italy an instrument to measure patient satisfaction with epilepsy surgery, the 19-item Epilepsy Surgery Satisfaction Questionnaire (ESSQ-19). METHODS Consecutive patients with epilepsy who received epilepsy surgery between the years 2018-2021 at Modena Academic Hospital were recruited and provided clinical and demographic data. The Italian version of the ESSQ-19 and other three questionnaires were completed to assess construct validity. To evaluate the validity and reliability of the tool Spearman's rank correlation, and internal consistency analysis were performed. RESULTS 66 out of 79 eligible patients participated in the study (22 females; median age 37 years). The mean values of satisfaction for each domain of the IT-ESSQ-19 were: seizure control 83.4; (SD 16.7), psychosocial functioning 79.3 (SD 17.1), surgical complications 90.8 (SD 14.9), and recovery from surgery 81.4 (SD 16.9). The mean summary score was 83.7 (SD 13.3). The questionnaire was shown to have high internal consistency in the four domains (Cronbach's alpha = 0.82-0.93), and no significant floor/ceiling effects of the summary score. The ESSQ-19 scores significantly correlated with other instruments to support construct validity. It also demonstrated good discriminant validity for being seizure free [AUC 0.72; 95% CI = 0.56-0.88], and to endorse depression [AUC 0.76, 95% CI = 0.56-0.96]. SIGNIFICANCE The Italian version of the ESSQ-19 is a reliable and valid self-reported questionnaire for assessing patient satisfaction with epilepsy surgery.
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Affiliation(s)
- Margherita Burani
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria Di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Giada Giovannini
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria Di Modena, Modena, Italy
| | - Matteo Pugnaghi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria Di Modena, Modena, Italy
| | - Niccolò Orlandi
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria Di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Maria Cristina Cioclu
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Anna Elisabetta Vaudano
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria Di Modena, Modena, Italy
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
| | - Elisa Moriconi
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
- Neurosurgery, OCB Hospital, Azienda Ospedaliera-Universitaria Di Modena, Modena, Italy
| | - Giacomo Pavesi
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy
- Neurosurgery, OCB Hospital, Azienda Ospedaliera-Universitaria Di Modena, Modena, Italy
| | - Stefano Meletti
- Neurology Unit, OCB Hospital, Azienda Ospedaliera-Universitaria Di Modena, Modena, Italy.
- Department of Biomedical, Metabolic and Neural Science, Center for Neuroscience and Neurotechnology, University of Modena and Reggio Emilia, Modena, Italy.
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Haneef Z, Patel K, Nguyen A, Kayal G, Martini SR, Sullivan-Baca E. Epilepsy surgery perceptions among general neurologists and epilepsy specialists: A survey. Clin Neurol Neurosurg 2024; 237:108151. [PMID: 38340429 DOI: 10.1016/j.clineuro.2024.108151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/29/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVE Surgical intervention for drug-resistant epilepsy (DRE) is a safe and efficacious evidence-based treatment. Yet, neurologists have historically revealed hesitance in referring patients for surgical evaluations. The present study surveyed general neurologists and epilepsy specialists to assess their views and process in referring patients for specialized epilepsy care and epilepsy surgery. METHODS A 14-item survey assessing epilepsy referrals and views of epilepsy surgery was distributed to all neurologists currently practicing in a large national integrated health system using REDCap. Responses were qualitatively analyzed and differences between general neurologists and epileptologists were assessed using chi-squared tests. RESULTS In total, 100 responses were received from 67 general neurologists and 33 epileptologists with several similarities and differences emerging between the two groups. Both groups endorsed surgery and neuromodulation as treatment options in DRE, felt that seizure frequency rather than duration was relevant in considering epilepsy surgery, and indicated patient preference as the largest barrier limiting epilepsy surgery. General neurologists were more likely to require ≥ 3 ASMs to fail to diagnose DRE compared to epileptologists (45% vs. 15%, p < 0.01) who more often required ≥ 2 ASMs to fail. Epileptologists were also more likely than neurologists to try a new ASM (75.8% vs. 53.7%, p < 0.05) or optimize the current ASM (75.8% vs. 49.3%, p < 0.05) in DRE. General neurologists were more likely to consider epilepsy surgery to be less efficacious (p = 0.001) or less safe (p < 0.05). SIGNIFICANCE Overall, neurologists appear to have generally positive opinions of epilepsy surgery, which is a change from prior literature and represents a changing landscape of views toward this intervention. Furthermore, epileptologists and general neurologists endorsed more similarities than differences in their opinions of surgery and steps to referral, which is another encouraging finding. Those gaps that remain between epileptologists and general neurologists, particularly in standards of ASM prescription, may be addressed by more consistent education about DRE and streamlining of surgical referral procedures.
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Affiliation(s)
- Zulfi Haneef
- Epilepsy Centers of Excellence, Veteran's Health Administration, USA; Department of Neurology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA; Neurology Care Line, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA.
| | - Kamakshi Patel
- Department of Neurology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA; Neurology Care Line, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA
| | - Angela Nguyen
- University of Houston, 4800 Calhoun Road, Houston, TX 77204, USA
| | - Gina Kayal
- Department of Neurology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA; Neurology Care Line, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA
| | - Sharyl R Martini
- Department of Neurology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA; Neurology Care Line, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA
| | - Erin Sullivan-Baca
- Department of Neurology, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA; Neurology Care Line, Michael E. DeBakey VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030, USA
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Fukuyama T, Yabe M, Nishioka M, Natsume T, Hoshino Y, Kanaya K, Takano K, Kobayashi N, Inoue Y. Characteristics of an advanced epilepsy treatment gap in a region in Japan. Epilepsy Behav Rep 2023; 24:100628. [PMID: 37886219 PMCID: PMC10598686 DOI: 10.1016/j.ebr.2023.100628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/26/2023] [Accepted: 10/15/2023] [Indexed: 10/28/2023] Open
Abstract
To investigate the quality of epilepsy care in a region in Japan that lacked specialised care, we retrospectively evaluated patients who visited our newly established epilepsy division between April 2018 and March 2021, and had been treated with anti-seizure medications (ASMs) for at least 1 year prior. Of the 231 patients included, 169 had ongoing seizure episodes at first visit (seizure-persist group) and 62 had no seizure episodes for more than a year (seizure-free group). Eighty-three patients in the seizure-persist group had not received specialised epilepsy care, 15 had been treated with unnecessary medications, and seven had experienced side effects from ASMs. Twelve patients in the seizure-free group had been treated with unnecessary ASMs, 10 had been treated with ASMs with teratogenic potential and four had experienced ASM side effects. These patients could be classified as having an advanced epilepsy treatment gap (ETG) because they had not previously received necessary specialised care. The progressive decline in the number of patients with advanced ETG suggests that our new epilepsy division has addressed this issue. This study highlights that a significant number of patients with advanced ETGs exist in Japan and that proper countermeasures are required to address this gap.
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Affiliation(s)
- Tetsuhiro Fukuyama
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
- Division of Epilepsy, Shinshu University Hospital, Matsumoto, Japan
| | - Manami Yabe
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Makoto Nishioka
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Takenori Natsume
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Yuumi Hoshino
- Division of Epilepsy, Shinshu University Hospital, Matsumoto, Japan
- Department of Neurology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kohei Kanaya
- Division of Epilepsy, Shinshu University Hospital, Matsumoto, Japan
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Kyoko Takano
- Center of Medical Genetics, Shinshu University Hospital, Matsumoto, Japan
| | | | - Yushi Inoue
- National Epilepsy Center, NHO Shizuoka Institute of Epilepsy and Neurological Disorders, Japan
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Hill CE, Lin CC, Terman SW, Zahuranec D, Parent JM, Skolarus LE, Burke JF. Predictors of referral for long-term EEG monitoring for Medicare beneficiaries with drug-resistant epilepsy. Epilepsia Open 2023; 8:1096-1110. [PMID: 37423646 PMCID: PMC10472378 DOI: 10.1002/epi4.12789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/02/2023] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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). SIGNIFICANCE 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.
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Affiliation(s)
- Chloe E. Hill
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Chun Chieh Lin
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
- Department of NeurologyThe Ohio State UniversityColumbusOhioUSA
| | - Samuel W. Terman
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Darin Zahuranec
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Jack M. Parent
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | | | - James F. Burke
- Department of NeurologyThe Ohio State UniversityColumbusOhioUSA
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