A framework for health equity in people living with epilepsy

Assessing multilevel provider knowledge and confidence in identifying and addressing gaps in epilepsy care

RATIONALE

People with epilepsy (PWE) face many disparities in healthcare. Standardized epilepsy self-management (ESM) programs have demonstrated benefits in health outcomes and quality of life for PWE. However, ESM practices and behaviors are less commonly implemented among PWE from underserved populations. This project aims to identify gaps in knowledge and confidence surrounding epilepsy care inclusive of ESM that exist among epilepsy specialist clinicians (ESC) and non-specialist clinicians (NSC).

METHODS

Two surveys were designed, one for ESC and one for NSC, to identify respondents' perceived level of knowledge and confidence in practice about ESM, stigma, treatment and seizure first aid as well as the respondents' self-rating of their knowledge and awareness of social determinants of health (SDOH) affecting epilepsy care. Face and content validity were established, and surveys were delivered electronically. Data analysis was descriptive.

RESULTS

276 responses were analyzed. Strong correlation between knowledge and confidence was observed for both ESC (r = 0.91) and NSC (r = 0.89) across all epilepsy care domains surveyed. ESC subgroup analysis demonstrated a significant difference between epileptologists and neurologists (p < 0.0004) regarding knowledge for counseling patients on ESM skills (p < 0.002), knowledge of available ESM programs, (p < 0.02) and referral to ESM (p < 0.001). Significant differences were observed between ESC and NSC regarding counseling patients on ESM skills (p < 0.0001), knowledge of available of ESM programs (p < 0.0006), and referral to ESM programs (<0.008).

CONCLUSIONS

Professional education addressing the needs of both ESC and NSC is necessary for improvements in health outcomes and quality of life for PWE.

Evolving trends and burden of idiopathic epilepsy among children (0-14 years), 1990-2021: a systematic analysis for the Global Burden of Disease study 2021

Objective

This systematic analysis aims to elucidate the trends and burden of idiopathic epilepsy among children aged 0 to 14 from 1990 to 2021, utilizing Global Burden of Disease (GBD) 2021 data to explore demographic and geographical variations, highlight progress, and identify ongoing challenges.

Methods

Data were sourced from the GBD 2021 database, focusing on children aged 0-14. Annual absolute numbers and age-standardized rates for incidence (ASIR), prevalence (ASPR), mortality (ASMR), and disability-adjusted life years (ASDR) of idiopathic epilepsy were retrieved. Joinpoint regression analyses assessed changes over time, calculating average annual percentage change (AAPC) statistics. Data collation and visualizations were conducted using R software, with statistical significance established at a p-value threshold of 0.05.

Results

In 2021, there were 1,227,191 incident cases, 6,095,769 prevalent cases, 3,564,497 DALYs, and 18,171 deaths due to idiopathic epilepsy globally. The ASIR increased by 0.27% from 55.74 to 61.35 per 100,000 population from 1990 to 2021. In contrast, ASPR (AAPC = -0.03), ASMR (AAPC = -1.60), and ASDR (AAPC = -1.01) all decreased. Regionally, the low-middle SDI region had the highest burden, while the high SDI region had the highest ASIR and ASPR. The low SDI region experienced the highest ASMR and ASDR. Significant regional variations were noted, with the African Region exhibiting the highest ASIR and ASDR, while the Western Pacific Region had the lowest. Nationally, substantial variations were observed across 204 countries, with notable differences in ASIR, ASPR, ASMR, and ASDR.

Conclusion

Despite overall declines in ASPR, ASMR, and ASDR, the slight increase in ASIR and regional disparities highlight ongoing challenges. Low and low-middle SDI regions continue to bear a higher burden, underscoring the need for targeted interventions and improved healthcare access. Future efforts should focus on strengthening healthcare systems, enhancing diagnostic and treatment capabilities, and increasing awareness, particularly in resource-limited regions.

Epilepsy Genetics

OBJECTIVE

This article reviews essential concepts and terminology in epilepsy genetics, discusses current guidance on when and how to pursue genetic evaluation, provides an overview of genetic syndromes, and offers illustrative examples of the effect of genetic diagnosis in epilepsy patient care.

LATEST DEVELOPMENTS

The growing availability of next-generation genetic sequencing methods for clinical use provides an opportunity to make etiologic diagnoses in a larger number of epilepsy patients, which can affect therapeutic management, prognostic counseling, surveillance for comorbid conditions, and other aspects of epilepsy care. Exome and genome sequencing may have high diagnostic yields in patients with unexplained epilepsy. The body of knowledge in epilepsy genetics is growing more complex, not only because of gene discovery but also because of an increasingly nuanced understanding of the varying pathophysiologic effects of specific types of variation within epilepsy genes.

ESSENTIAL POINTS

Genetic testing plays a key role in the evaluation of epilepsy patients. Clinicians caring for patients with epilepsy should understand patient selection, test selection, and result interpretation in genetic testing. The recommended first-line test in most patients is exome or genome sequencing.

About 1.5 million community-dwelling US adults with active epilepsy reported uncontrolled seizures in the past 12 months, and seizure control varied by annual family income-National Health Interview Survey, United States 2021 and 2022

Uncontrolled seizures among people with epilepsy increase risk of adverse health and social outcomes including increased risk of death. Previous population-based studies have reported suboptimal seizure control and disparities in seizure control among U.S. adults with active epilepsy (self-reported doctor-diagnosed epilepsy and taking anti-seizure medicine or with ≥ 1 seizures in the past 12 months) by annual family income. This brief is based upon data from the 2021 and 2022 National Health Interview Survey (NHIS) to provide updated national estimates of the percentages of adults with active epilepsy with and without seizure control (0 seizures in past 12 months) vs. ≥ 1) by anti-seizure medication use and by annual family income. Annual family income was operationalized with NHIS poverty-income ratio (PIR) categories (i.e., total family income divided by the US Census Bureau poverty threshold given the family's size and number of children): PIR < 1.0, 1.0 ≤ PIR < 2.0; PIR ≥ 2.0. Among the 1.1 % of US adults with active epilepsy in 2021/2022 (estimated population about 2.9 million), 49.2 % (∼1.4 million) were taking antiseizure medication and reported no seizures (seizure control), 36.2 % (∼1.1 million) were taking antiseizure medication and reported ≥ 1 seizures (uncontrolled seizures), and 14.7 % (∼400,000) were not taking antiseizure medication and had ≥ 1 seizures (uncontrolled seizures). The prevalence of seizure control among those with active epilepsy varied substantially by annual family income, with a larger percentage of adults with PIR ≥ 2.0 reporting seizure control compared with those with PIR < 1.0. Opportunities for intervention include improving provider awareness of epilepsy treatment guidelines, enhancing access and referral to specialty care, providing epilepsy self-management supports, and addressing unmet social needs of people with epilepsy with uncontrolled seizures, especially those at lowest family income levels.

Mortality and mortality disparities among people with epilepsy in the United States, 2011-2021

Studies on epilepsy mortality in the United States are limited. We used the National Vital Statistics System Multiple Cause of Death data to investigate mortality rates and trends during 2011-2021 for epilepsy (defined by the International Classification of Diseases, 10th Revision, codes G40.0-G40.9) as an underlying, contributing, or any cause of death (i.e., either an underlying or contributing cause) for U.S. residents. We also examined epilepsy as an underlying or contributing cause of death by selected sociodemographic characteristics to assess mortality rate changes and disparities in subpopulations. During 2011-2021, the overall age-standardized mortality rates for epilepsy as an underlying (39 % of all deaths) or contributing (61 % of all deaths) cause of death increased 83.6 % (from 2.9 per million to 6.4 per million population) as underlying cause and 144.1 % (from 3.3 per million to 11.0 per million population) as contributing cause (P < 0.001 for both based on annual percent changes). Compared to 2011-2015, in 2016-2020 mortality rates with epilepsy as an underlying or contributing cause of death were higher overall and in nearly all subgroups. Overall, mortality rates with epilepsy as an underlying or contributing cause of death were higher in older age groups, among males than females, among non-Hispanic Black or non-Hispanic American Indian/Alaska Native persons than non-Hispanic White persons, among those living in the West and Midwest than those living in the Northeast, and in nonmetro counties compared to urban regions. Results identify priority subgroups for intervention to reduce mortality in people with epilepsy and eliminate mortality disparity.

Factors Associated With Anxiety and Depression in Persons With Epilepsy (PWE)

INTRODUCTION

Epilepsy is a common neurological disease that is associated with increased morbidity and mortality globally. Persons with epilepsy (PWE) experience a heavy emotional burden mainly due to social stigmatization and limited opportunities in life. The purpose of this study was to explore factors associated with anxiety and depression in PWE.

MATERIAL AND METHODS

In the present cross-sectional study, we enrolled 100 PWE who visited outpatient settings in a public hospital for scheduled follow-up. Data collection was carried out by the completion of the Hospital Anxiety and Depression Scale (HADS), which included participants' characteristics. The statistical significance level was p < 0.05.

RESULTS

Of the 100 participants, the majority were women (65%), below 50 years old (62%), and single (40%). In terms of mental comorbidity, 58% and 48% experienced anxiety and depression, respectively. A statistically significant association was observed between anxiety and age (p = 0.002). Furthermore, a statistically significant association was observed between depression and gender (p = 0.044), age (p = 0.001), marital status (p = 0.036), educational level (p = 0.003), job (p = 0.025), residency (p = 0.041), and whether they went out at night (p = 0.009).

CONCLUSION

Identifying factors associated with anxiety and depression is essential for PWE to receive appropriate support.

Co-production of online educational resources for adolescent and young adult females with epilepsy

OBJECTIVE

To develop online patient education materials about epilepsy for adolescent and young adult females with epilepsy through co-production in partnership with patients, parents or caregivers, and multi-disciplinary healthcare providers who care for this population.

METHODS

We recruited participants from Western/Central Pennsylvania, comprised of females with epilepsy ages 18-26 or parents of children with epilepsy ages 12-26. Healthcare providers who participated in the study were recruited nationally from disciplines of pediatric epilepsy, adult epilepsy, women's neurology, and adolescent medicine. We held three series of meetings to create the online materials from July to August 2021.

RESULTS

Five adolescent and young adult females with epilepsy (ages 18-26, median age 22) and two parents of children with epilepsy were recruited and participated in meetings. The physician group was comprised of two adolescent medicine physicians, one adult neurologist with a specialization in women's neurology, one adult epileptologist, and one pediatric epileptologist. All participants were female. Several sets of meetings were held, which involved the creation of an empathy map to evaluate the needs and desires of our participants, topic list development, and specific content and formatting recommendations. After these meetings, content was created for the online materials and published on the Center for Young Women's Health (CYWH) website.

CONCLUSION

Our team utilized co-production with a diverse group of partners to create educational materials that met the interests of adolescent and young adult females with epilepsy. This is a structured and reproducible methodology that could inform future educational intervention development in epilepsy.

Health equity: A concept analysis

BACKGROUND

Although health equity is critically important for healthcare delivery, there are inconsistencies in its definitions or lack of definitions.

PURPOSE

Develop a comprehensive understanding of health equity to guide nursing practice and healthcare policy.

METHOD

Walker and Avant's concept analysis method was used to establish defining attributes, antecedents, consequences, and empirical referents of health equity.

FINDINGS

Health equity defining attributes are grounded in ethical principles, the absence of unfair and avoidable differences, and fair and just opportunities to attain a person's full health potential. Health equity antecedents are categorized into environmental; financial or economic; law, politics, and policy; societal and structural; research; and digital and technology.

DISCUSSION

Health equity's antecedents are useful to distinguish health disparities from health outcomes resulting from individual preferences. To achieve health equity, organizations need to focus on addressing the antecedents.

Disparities in adherence and emergency department utilization among people with epilepsy: A machine learning approach

PURPOSE

We used a machine learning approach to identify the combinations of factors that contribute to lower adherence and high emergency department (ED) utilization.

METHODS

Using Medicaid claims, we identified adherence to anti-seizure medications and the number of ED visits for people with epilepsy in a 2-year follow up period. We used three years of baseline data to identify demographics, disease severity and management, comorbidities, and county-level social factors. Using Classification and Regression Tree (CART) and random forest analyses we identified combinations of baseline factors that predicted lower adherence and ED visits. We further stratified these models by race and ethnicity.

RESULTS

From 52,175 people with epilepsy, the CART model identified developmental disabilities, age, race and ethnicity, and utilization as top predictors of adherence. When stratified by race and ethnicity, there was variation in the combinations of comorbidities including developmental disabilities, hypertension, and psychiatric comorbidities. Our CART model for ED utilization included a primary split among those with previous injuries, followed by anxiety and mood disorders, headache, back problems, and urinary tract infections. When stratified by race and ethnicity we saw that for Black individuals headache was a top predictor of future ED utilization although this did not appear in other racial and ethnic groups.

CONCLUSIONS

ASM adherence differed by race and ethnicity, with different combinations of comorbidities predicting lower adherence across racial and ethnic groups. While there were not differences in ED use across races and ethnicity, we observed different combinations of comorbidities that predicted high ED utilization.